Parents of an infant with an inguinal hernia bring their child to the emergency department reporting that the hernia has changed in color to dark purple and child has not had a bowel movement in 24 hours. The nurse obtains a Face, Legs, Activity, Cry, Consolability (FLACC) scale score of 8 on initial assessment. Which action should the nurse prioritize?

Report the assessment to the healthcare provider.

Determine when oral fluids were last taken.

Attempt to reduce the hernia manually.

Prepare to initiate venous access for an intravenous (IV) infusion

Answer and Explanation

The Correct Answer is A

A. Report the assessment to the healthcare provider.

The changing color of the inguinal hernia to dark purple is concerning and may indicate a possible strangulated hernia, which is a surgical emergency. Additionally, the absence of a bowel movement for 24 hours raises concerns about possible bowel obstruction or compromise. The FLACC score of 8 on the initial assessment suggests that the infant is experiencing significant discomfort or pain.

Therefore, the priority is to report the assessment findings to the healthcare provider to ensure timely evaluation and intervention. The healthcare provider needs to assess the hernia, determine if it is strangulated, and decide on the appropriate course of action, which may include surgery. It is essential to act promptly in this situation to prevent potential complications.

B. Determining when oral fluids were last taken is relevant but should not take precedence over the potential surgical emergency of a strangulated hernia.

C. Attempting to reduce the hernia manually is not advisable in this situation, as it may worsen the condition if the hernia is strangulated.

D. Preparing to initiate venous access for an intravenous (IV) infusion is a consideration but should follow the assessment and reporting of the potential surgical emergency. Intravenous access may be needed as part of the overall management, but the priority is to ensure the infant receives appropriate surgical evaluation and intervention.

A. Report the assessment to the healthcare provider.

B. Determining when oral fluids were last taken is relevant but should not take precedence over the potential surgical emergency of a strangulated hernia.

C. Attempting to reduce the hernia manually is not advisable in this situation, as it may worsen the condition if the hernia is strangulated.

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Correct Answer is B

Explanation

When advising a new mother in caring for a child with croup, the symptom that should be a priority concern to the telephone triage nurse is B.

Explanation:

A. A fever of 101.0°F (38.3°C) is a common symptom in many childhood illnesses, including croup, but it is not the primary concern when difficulty swallowing secretions is present.

B Difficulty swallowing secretions.

Croup is characterized by a barking cough and may also be associated with stridor (noisy breathing), hoarseness, and difficulty swallowing secretions. While all the symptoms mentioned can be concerning, difficulty swallowing secretions is a priority concern because it can potentially lead to respiratory distress if not managed appropriately. Thick secretions can cause airway obstruction, and prompt assessment and intervention are needed to ensure the child's airway remains clear and that the child is able to breathe effectively.

C. A barking cough, worse at night, is a classic symptom of croup and should be addressed, but difficulty swallowing secretions can have a more direct impact on the child's airway.

D. Crying often when nursing may be related to the discomfort caused by croup, but it is not as immediately concerning as difficulty swallowing secretions.

While the barking cough, hoarseness, and other croup symptoms should also be addressed, the priority is ensuring that the child is able to manage secretions effectively without respiratory distress. The telephone triage nurse should provide guidance to the mother on how to help the child manage these secretions and when to seek medical attention if the situation worsens.

A. Edema B. Irritability C. Fatigue D. Dry skin E. Intense thirst F. Muscle weakness G. Hypertension

Correct Answer is ["A","D","E","F"]

Explanation

A. Edema can be a symptom to watch for, as it may indicate fluid retention or imbalance, especially in a client who has received intravenous fluids.

D. Dry skin may be a symptom to observe, as it could suggest dehydration or fluid imbalances.

E. Intense thirst is a symptom to be alert for, as it may be an indication of dehydration or an electrolyte imbalance.

F. Muscle weakness is a potential symptom to monitor for, as it could be related to electrolyte imbalances or other complications following surgery and injury.

B, C, and G are not the primary symptoms to expect based on the client's information and history, but they should still be monitored as part of routine assessment. Irritability and fatigue can be nonspecific symptoms that may occur in various clinical situations. Hypertension may or may not be a symptom, and it is essential to assess the client's blood pressure in the context of their overall condition.

The client's history and the presence of medical devices and surgical intervention indicate the need for close monitoring of fluid balance and electrolyte status.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When advising a new mother in caring for a child with croup, which symptom should be a priority concern to the telephone triage nurse?

Correct Answer is B

Explanation

Correct Answer is ["A","D","E","F"]

Explanation

A 6-year-old boy with bronchial asthma takes the beta-adrenergic agonist agent albuterol. The child's mother tells the nurse that she uses this medication to open her son's airway when he is having trouble breathing. What is the nurse's best response?

A 10-year-old boy has been seen frequently by the school nurse over the past three weeks after school begins in the fall. He reports headaches, stomach aches, and difficulty sleeping. Which intervention should the nurse implement?

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The nurse begins collecting the medical history of a child when the child screams and tries to hide behind the parent, dropping a stuffed toy. Which intervention should the nurse implement?

An infant born 2 days ago has not passed a meconium stool and begins to vomit bilious secretions. Which action should the nurse take first?

During her sports physical examination, a 15-year-old female requests oral contraceptives. She explains that she is sexually active and does not want her parents to know. Which action should the nurse take?