A six-year-old girl is brought to the emergency department. She has a "frog-like croaking sound" on inspiration, is agitated, and is drooling. She insists on sitting upright. The nurse should first do which of the following?
Get emergency equipment at the bedside.
Make her lie down and rest quietly.
Complete a thorough neurological assessment.
Auscultate her lungs and prepare for administering oxygen.
The Correct Answer is A
Choice A reason: This is the correct answer because the girl's symptoms indicate that she may have epiglottitis, a life-threatening condition that causes swelling of the epiglottis and obstructs the airway. The nurse should be prepared for a possible intubation or tracheostomy.
Choice B reason: This is not the correct answer because making the girl lie down and rest quietly may worsen her respiratory distress and anxiety. The girl should be allowed to sit in a position of comfort and ease of breathing.
Choice C reason: This is not the correct answer because a thorough neurological assessment is not the priority in this situation. The nurse should focus on the girl's airway, breathing, and circulation.
Choice D reason: This is not the correct answer because auscultating the lungs and preparing for administering oxygen may not be sufficient to manage the girl's airway obstruction. The nurse should also have emergency equipment ready and call for assistance.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This is not appropriate because it may make the parents feel excluded or suspicious. It may also make the girl feel uncomfortable or scared. The parents have the right to be present and involved in their daughter's care, unless they pose a threat to her safety.
Choice B reason: This is not appropriate because it may offend or upset the parents and the girl. It may also damage the trust and rapport between the provider and the family. The provider should not make assumptions or accusations based on the girl's symptoms.
Choice C reason: This is appropriate because it respects the parents' authority and the girl's privacy. It also allows the provider to rule out pregnancy as a possible cause of the abdominal pain, and to offer appropriate counseling and treatment if needed.
Choice D reason: This is not appropriate because it may miss a potential diagnosis or complication. The provider should not rely solely on the parents' or the girl's statements about sexual activity, as they may be inaccurate or dishonest. The provider should follow the standard of care and perform a pregnancy test for any female of childbearing age with abdominal pain.
Correct Answer is D
Explanation
Choice A reason: APT stands for Acute Pain Team, which is a multidisciplinary team that provides pain management for patients. It is not a tool to assess pain.
Choice B reason: Numeric is a pain scale that uses numbers from 0 to 10 to rate the intensity of pain. It is not suitable for a 4-year-old child who may not understand the concept of numbers or have difficulty expressing their pain level.
Choice C reason: FLACC stands for Face, Legs, Activity, Cry, and Consolability. It is a pain scale that uses behavioral cues to assess pain in infants and young children who are unable to verbalize their pain. It is more appropriate for children under 3 years of age.
Choice D reason: FACES is a pain scale that uses facial expressions to indicate the level of pain. It is suitable for a 4-year-old child who can point to the face that matches their pain. It is a simple and easy way to assess pain in children.
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