In the Emergency Department, four children are awaiting treatment for respiratory illnesses.
Given that only one treatment room is available, which child should be prioritized based on the assessment findings?
A 12-month-old with a weak cry, pale complexion, decreased breath sounds, retractions, and an oxygen saturation of 93%.
A 5-year-old speaking in full sentences, pink complexion, bilateral wheezing, and an oxygen saturation of 93%.
A 16-year-old speaking in short phrases, wheezing, sitting upright, and an oxygen saturation of 93%.
A 9-year-old who is quiet, pale, sitting on his father’s lap, bilateral wheezing, and an oxygen saturation of 93%.
The Correct Answer is A
Choice A rationale
A 12-month-old with a weak cry, pale complexion, decreased breath sounds, retractions, and an oxygen saturation of 93% is showing signs of severe respiratory distress. The weak cry and pale complexion suggest poor oxygenation and possible hypoxia. Decreased breath sounds and retractions indicate the child is struggling to breathe. An oxygen saturation of 93% is below the normal range for infants, further indicating respiratory distress. This child should be prioritized for treatment.
Choice B rationale
A 5-year-old speaking in full sentences, pink complexion, bilateral wheezing, and an oxygen saturation of 93% is showing signs of respiratory distress, but not as severe as Choice A12. The ability to speak in full sentences and having a pink complexion suggest that the child is getting
enough oxygen. However, bilateral wheezing indicates some airway obstruction. An oxygen saturation of 93% is on the lower end of the normal range for children this age.
Choice C rationale
A 16-year-old speaking in short phrases, wheezing, sitting upright, and an oxygen saturation of 93% is also showing signs of respiratory distress. Speaking in short phrases and sitting upright are signs that the teenager is working harder to breathe. Wheezing indicates airway obstruction. An oxygen saturation of 93% is on the lower end of the normal range for teenagers.
Choice D rationale
A 9-year-old who is quiet, pale, sitting on his father’s lap, bilateral wheezing, and an oxygen saturation of 93% is showing signs of respiratory distress. Being quiet and pale can indicate poor oxygenation. Bilateral wheezing suggests airway obstruction. An oxygen saturation of 93% is below the normal range for children this age. However, this child’s symptoms are not as severe as those of the 12-month-old in Choice A.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
These therapies will decrease our child’s resistance to respiratory infections. This statement is incorrect. The therapies mentioned - chest physiotherapy (CPT), use of a flutter valve, and a cough assist machine - do not directly decrease a child’s resistance to respiratory infections.
Instead, they help manage the symptoms of cystic fibrosis by helping to clear mucus from the lungs, which can improve lung function and reduce the risk of lung infections.
Choice B rationale
These therapies will only be done when our child is showing signs of illness. This statement is incorrect. These therapies are part of the daily management of cystic fibrosis and are typically done regularly, not just when the child is showing signs of illness.
Choice C rationale
These therapies will help to loosen our child’s secretions and allow for better expectoration. This statement is correct. The goal of these therapies is to help clear thick, sticky mucus from the lungs, which can improve breathing and reduce the risk of lung infections.
Choice D rationale
These therapies will allow for the removal of mucus from our child’s GI tract that blocks digestion. This statement is incorrect. While cystic fibrosis can affect the digestive system by causing thick mucus to block the tubes that carry digestive enzymes from your pancreas to your small intestine, the therapies mentioned are primarily used to help clear mucus from the lungs.
Correct Answer is A
Explanation
Choice A rationale
Seizures, confusion, and weakness are symptoms that a nurse should anticipate when assessing a child suffering from hypotonic hyponatremia with a sodium level below 114
mEq/L2. Severe hyponatremia can lead to cerebral edema, resulting in neurologic symptoms such as seizures and confusion.
Choice B rationale
Mild tingling and numbness in fingers are not typically associated with hyponatremia. These symptoms are more commonly associated with conditions affecting the nervous system or with electrolyte imbalances such as hypocalcemia.
Choice C rationale
Frequent urination and fluid retention are not typical symptoms of hyponatremia. They are more commonly associated with conditions such as kidney disease or heart failure.
Choice D rationale
A temperature of 96°F orally and drowsiness are not specific symptoms of hyponatremia. While drowsiness can occur with severe hyponatremia due to cerebral edema, a low body temperature is not typically associated with this condition.
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