The caregivers of a 2-year-old who has had a common cold for 4 days calls the nurse in the emergency department at 2 AM on a cold winter night to say that the child has awakened with a barking cough and an elevated temperature. The caregiver reports she has taken the child into the bathroom and ran hot water for 15 minutes and now the child seems blue around her mouth The nurse would most appropriately recommend what action to the caregiver?
“Bring the child to the emergency room immediately.”
“Bundle the child up and take her out into the cold for a few minutes. Call back if the exposure to the cold air does not provide relief.”
“Take the child into the steam-filled room for an additional 15 minutes. If there is no relief, bring the child to the emergency room.”
“Put a cool mist humidifier or vaporizer in the room to see if that relieves the cough. Call back if there’s no relief in an hour.”
The Correct Answer is A
A. “Bring the child to the emergency room immediately.”
This is the most appropriate recommendation given the symptoms described, including the barking cough, elevated temperature, and blueness around the mouth. These signs may indicate respiratory distress, and immediate medical attention is needed.
B. “Bundle the child up and take her out into the cold for a few minutes. Call back if the exposure to the cold air does not provide relief.”
Taking a child out into the cold is not a recommended intervention for respiratory distress. This action may exacerbate the child's breathing difficulties. The symptoms described require urgent evaluation in a healthcare setting.
C. “Take the child into the steam-filled room for an additional 15 minutes. If there is no relief, bring the child to the emergency room.”
While steam may provide temporary relief for mild respiratory symptoms, the presence of blueness around the mouth suggests a more severe condition. Delaying care by waiting for an additional 15 minutes may not be appropriate in this situation.
D. “Put a cool mist humidifier or vaporizer in the room to see if that relieves the cough. Call back if there’s no relief in an hour.”
Using a cool mist humidifier may be helpful for mild respiratory symptoms, but the severity of the symptoms described, especially blueness around the mouth, indicates a need for immediate medical attention. Waiting for an hour could lead to worsening of the child's condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["-195"]
Explanation
The water intake is half of 900 mL, which is 450 mL. The soft drink intake is 12 oz, which is equivalent to 355 mL. Therefore, the total fluid intake is 450 + 355 = 805 mL.
The urine output is the sum of the two voids, which is 600 + 350 = 950 mL. The drainage output is 50 mL. Therefore, the total fluid output is 950 + 50 = 1000 mL.
The net I/O is the difference between the fluid intake and output, which is 805 - 1000 = -195 mL. This means that the patient had a negative fluid balance of 195 mL during the night.
Correct Answer is B
Explanation
A. Sore throat:
A sore throat is a common symptom of various respiratory tract infections, including acute epiglottitis. However, examining the throat with a tongue depressor is unlikely to directly precipitate a sore throat in this context.
B. Complete obstruction:
Examining the child's throat with a tongue depressor in acute epiglottitis can potentially trigger spasm or swelling of the already inflamed epiglottis, leading to a rapid and complete obstruction of the airway. This is a critical concern and is why healthcare providers approach suspected cases of epiglottitis with great caution.
C. Inspiratory stridor:
Inspiratory stridor (high-pitched sound during inhalation) is a common symptom of upper airway obstruction, including in conditions like acute epiglottitis. It may be present without manipulation, but using a tongue depressor in the throat could exacerbate this symptom.
D. Respiratory tract infection:
Acute epiglottitis is indeed a type of respiratory tract infection. However, examining the throat with a tongue depressor is not likely to directly precipitate a respiratory tract infection.
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