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 A
Explanation
Choice A rationale
By 9 months, most babies have developed the fine motor skills necessary to pick up small objects, like crackers, with their thumb and forefinger. This is known as the pincer grasp. If a 9- month-old child is unable to do this, it could be a sign of a developmental delay.
Choice B rationale
It’s normal for babies at this age to have a short attention span. They often play with a toy for only a few minutes before moving on to something else. Therefore, this behavior is not typically a cause for concern.
Choice C rationale
The ability to crawl on all fours supported on hands and knees is a typical developmental milestone for a 9-month-old child. Therefore, this behavior is expected and does not indicate a developmental delay.
Choice D rationale
While some 9-month-old babies may be able to pull themselves to a standing position, not all babies develop this skill at the same time. Therefore, the inability to do this is not necessarily a cause for concern.
Correct Answer is B
Explanation
Choice A rationale
Distracting the patient and then taking the blanket for washing might seem like a practical solution, but it can lead to trust issues. The patient may feel betrayed or tricked, which can negatively affect the therapeutic relationship between the nurse and the patient.
Choice B rationale
Acknowledging that the blanket seems to be his favorite and allowing him to keep it with him is the best course of action. The blanket likely provides comfort and security to the patient.
Taking it away, even temporarily, can cause distress. The nurse should respect the patient’s attachment to the blanket and look for alternative solutions for maintaining hygiene, such as offering to clean the blanket when the patient is ready to part with it temporarily.
Choice C rationale
Telling the patient that you want to take the blanket home to wash and that you will bring it back might not be reassuring enough for the patient. The patient may worry about the blanket getting lost or not returned, which can cause unnecessary anxiety.
Choice D rationale
Suggesting getting him another blanket so that he will not mind giving up the current one might not work. The patient’s attachment is likely to the specific blanket, not to blankets in general. A new blanket will not have the same familiarity and comforting effect as the old one.
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