Chapter 40 Prep U Piliterri
A 2-year-old child has had a common cold for 4 days. The caregiver calls the nurse in the emergency department at 2 a.m. on a cold winter night to say that the child has awakened with a barking cough and an elevated temperature; the child seems blue around the mouth. The nurse would appropriately recommend what action to the caregiver? "Put a cool mist humidifier or vaporizer in the room to see if that relieves the cough. Call back if there is no relief in an hour." "Bundle the child up and take the child out into the cold for a few minutes. Call back if the exposure to the cold air does not provide relief." "Bring the child to the emergency room immediately." "Turn on all of the hot water taps in the bathroom and close the door. Take the child into the steam-filled room for 15 minutes. If there is no relief, bring the child to the emergency room."
"Bring the child to the emergency room immediately." Explanation: Acute laryngotracheobronchitis generally occurs after an upper respiratory infection with fairly mild rhinitis and pharyngitis. The child develops hoarseness and a barking cough with a fever that may reach 104° F (40° C) to 105° F (40.6° C). As the disease progresses, marked laryngeal edema occurs and the child's breathing becomes difficult; the pulse is rapid and cyanosis may appear. Heart failure and acute respiratory distress can result. The child needs to be treated immediately. Humidified air is helpful in reducing laryngospasm; humidifiers may be used in the child's bedroom to provide high humidity. Cool humidifiers are recommended, but vaporizers also may be used. Taking the child into the bathroom and opening the hot water taps with the door closed is a quick method for providing moist air, if the water runs hot enough. Sometimes the spasm is relieved by exposure to cold air: for instance, when the child is taken out into the night to go to the emergency department or to see the physician.
A 9-year-old female child was brought to the emergency department after experiencing wheezing and shortness of breath while playing soccer. The parents administered two puffs of albuterol metered dose inhaler (MDI) with little effect, and 911 was notified. Paramedics applied oxygen 2 liters by nasal cannula for oxygen saturation of 90% on room air, and administered an albuterol nebulizer treatment. Audible wheezing was heard, and a 20-gauge intravenous (IV) catheter was inserted. Vital signs upon arrival at the emergency room: temperature, 98.8°F (37.1°C); heart rate, 125 beats/min; blood pressure, 88/50 mm Hg; respiratory rate, 32 breaths/min; oxygen saturation, 92% on simple face mask. Child appears anxious. Complete the following sentence(s) by choosing from the lists of options. The emergency room nurse should first assess airway assess circulation assess level of consciousness then administer intravenous (IV) methylprednisolone, administer albuterol MDI, instruct client to use a peak flow meter.
1. The nurse should assess the child's airway first. Assessment should always be prioritized using the ABCs (airway, breathing, and circulation). 2. Intravenous (IV) methylprednisolone should be administered promptly to decrease inflammation in the lungs, which will improve air flow. Circulation would be assessed after airway and breathing. Level of consciousness is simultaneously checked with ABCs (airway, breathing, and circulation), but the nurse must first perform a focused respiratory assessment and implement interventions promptly to prevent respiratory arrest. Metered-dose inhalers would not be used in status asthmaticus. Aerosol nebulizer treatments would be administered. Because the child is in severe respiratory distress, the nurse would not perform peak flow meter instruction at this time.
The nurse is caring for a 3-month-old child with acute bronchiolitis; the child's parents are very anxious. When providing teaching, which topics are most important? Select all that apply. It is caused by respiratory syncytial virus. Suprasternal and subcostal retractions are often present. Intravenous antibiotics are likely to be prescribed. Respiratory rate may be 60 to 80 breaths per minute. Dyspnea is present for several weeks prior to diagnosis.
It is caused by respiratory syncytial virus. Suprasternal and subcostal retractions are often present. Respiratory rate may be 60 to 80 breaths per minute. When parents are anxious about a child's illness, education is essential. Begin with the cause of the disease and then progress to common symptoms. It is caused by respiratory syncytial virus. The onset of dyspnea is abrupt. Manifestations include suprasternal and subcostal retractions are present. Respirations are 60 to 80 breaths per minute. Antibiotics are ineffective due to the viral etiology.
The caregivers of a child who was diagnosed with cystic fibrosis 5 months ago report that they have been following all of the suggested guidelines for nutrition, fluid intake, and exercise, but the child has been having bouts of constipation and diarrhea. The nurse tells the caregiver to increase the amount of which substance in the child's diet? Iodized salt Saturated fat Pancreatic enzymes Calories from protein
Pancreatic enzymes Explanation: Adequate nutrition helps the child resist infections. Pancreatic enzymes must be administered with all meals and snacks. If the child has bouts of diarrhea or constipation, the dosage of enzymes may need to be adjusted. The child's diet should be high in carbohydrates and protein with no restriction of fats. The child may need 1.5 to 2 times the normal caloric intake to promote growth. Low-fat products can be selected if desired. The child also may require additional salt in the diet. Increased caloric intake compensates for impaired absorption.
The caregivers of a child who was diagnosed with cystic fibrosis 5 months ago report that they have been following all of the suggested guidelines for nutrition, fluid intake, and exercise, but the child has been having bouts of constipation and diarrhea. The nurse tells the caregiver to increase the amount of which substance in the child's diet? Iodized salt Saturated fat Pancreatic enzymes Calories from protein
Pancreatic enzymes Explanation: Adequate nutrition helps the child resist infections. Pancreatic enzymes must be administered with all meals and snacks. If the child has bouts of diarrhea or constipation, the dosage of enzymes may need to be adjusted. The child's diet should be high in carbohydrates and protein with no restriction of fats. The child may need 1.5 to 2 times the normal caloric intake to promote growth. Low-fat products can be selected if desired. The child also may require additional salt in the diet. Increased caloric intake compensates for impaired absorption.
During an assessment, a child exhibits an audible high-pitched inspiratory noise, a tripod stance and intercostal retractions. Using SBAR communication, the nurse notifies the health care provider and states which breath sounds that are congruent with the clinical presentation of the child? Respiratory stridor Wheezing in the bases Rales in the middle lobe Rhonchi throughout the lung
Respiratory stridor Explanation: Stridor is a high-pitched, readily audible inspiration noise that indicates an upper airway obstruction. The child presents in severe respiratory compromise and struggles to breathe. A wheeze is a high-pitched sound heard on auscultation, usually on expiration. It is due to obstruction in the lower trachea or bronchioles. Rales are crackling sounds heard on auscultation when the alveoli become fluid filled. Rhonchi is a snoring sound heard throughout the lung field when inflammation occurs.
A nurse is caring for an infant admitted with a diagnosis of bronchiolitis. After completing an assessment, the nurse creates a plan of care for the infant. Which client goal would be priority in the plan of care? The infant will attain oxygen saturation of 90% on room air. The infant's airway will remain clear and free of mucus. The infant's breathing will be less labored. The infant will have decreased nasal stuffiness.
The infant's airway will remain clear and free of mucus. Explanation: Keeping the infant's airway clear is the top priority. An O2 saturation of 90% on room air is minimally acceptable. It is important that the infant's breathing be less labored and that there is decreased nasal stuffiness, but having the airway clear and free of mucus is most important.
A nurse is caring for an infant admitted with a diagnosis of bronchiolitis. After completing an assessment, the nurse creates a plan of care for the infant. Which client goal would be priority in the plan of care? The infant will attain oxygen saturation of 90% on room air. The infant's airway will remain clear and free of mucus. The infant's breathing will be less labored. The infant will have decreased nasal stuffiness.
The infant's airway will remain clear and free of mucus. Explanation: Keeping the infant's airway clear is the top priority. An O2 saturation of 90% on room air is minimally acceptable. It is important that the infant's breathing be less labored and that there is decreased nasal stuffiness, but having the airway clear and free of mucus is most important.
The nurse caring for the child with asthma weighs the child daily. What is the most important reason for doing a daily weight on this child? To determine medication dosages To monitor the child's growth pattern To ensure that the child's food intake is adequate To determine fluid losses
To determine fluid losses Explanation: During an acute asthma attack the child may lose a great quantity of fluid through the respiratory tract and may have poor oral intake because of coughing and vomiting. Theophylline administration also has a diuretic effect, which compounds the problem. Weigh the child daily to help determine fluid losses. The child's weight is used to determine medication dosages, to ensure that the child is appropriately gaining weight and growing, and that the intake is adequate. However, the most important reason for a daily weight is to determine fluid loss.
The caregivers of an 8-year-old bring their child to the pediatrician and report that the child has not had breathing problems before, but since taking up lacrosse the child has been coughing and wheezing at the end of every practice and game. Their friend's child has often been hospitalized for asthma; they are concerned that their child has a similar illness. The nurse knows that because the problems seem to be directly related to exercise, it is likely that the child will be able to be treated with: decreased activity and increased fluids. corticosteroids and leukotriene inhibitors. removal of allergens in the home and school. a bronchodilator and mast cell stabilizers.
a bronchodilator and mast cell stabilizers. Explanation: Mast cell stabilizers are used to help decrease wheezing and exercise-induced asthma attacks. A bronchodilator often is given to open up the airways just before the mast cell stabilizer is used. Corticosteroids are anti-inflammatory drugs used to control severe or chronic cases of asthma. Leukotriene inhibitors are given by mouth along with other asthma medications for long-term control and prevention of mild, persistent asthma.
A child has been prescribed a nasal cannula for oxygen delivery. What should the nurse do before applying the cannula? assess patency of the nares test the oxygen saturation add humidification to the delivery device assess the lung sounds
assess patency of the nares Explanation: A nasal cannula is a good delivery device for children because it allows them to eat and talk unobstructed. Because the device is designed for flow through the nares, the patency of the nares should be assessed prior to using the cannula. If the nares are blocked from secretions, suctioning may be required. If there is a defect in the upper airway causing blockage, the nasal cannula may not be an appropriate oxygen delivery device. The oxygen saturation should have been measured and used as a guide for the prescription of oxygen therapy. Adding humidification is a way to keep the upper airways from becoming too dry, but oxygen can be started before humidity is added. Anytime a child is sick enough to require oxygen all respiratory assessments, including lung sounds, should be done. It does not matter, however, what the lung sounds are if the child is in enough distress to require oxygen. The lung sounds can be assessed after oxygen is started.
A community health nurse is conducting a parenting class on respiratory syncytial virus (RSV). What statement made by a parent indicates that the teaching has been successful? "RSV season occurs primarily April through September." "Exposure to second- or thirdhand smoke increases the risk for developing RSV." "Infants are less affected by RSV than older children." "Early initiation of antibiotics can lessen the severity of the infection."
"Exposure to second- or thirdhand smoke increases the risk for developing RSV." Explanation: An infant exposed to second- or thirdhand smoke is at risk for developing respiratory syncytial virus (RSV). RSV season runs from September through April. Current treatment recommendations for RSV do not include antibiotics. Infants are susceptible to RSV much more than older children.
Which clinical manifestation of acute nasopharyngitis is more of a concern for the infant than the older child? Fever Vomiting Nasal congestion Diarrhea
Nasal congestion Explanation: The infant has smaller airways, making it more difficult to breathe when nasal congestion occurs. The older child can tolerate the congestion better than the infant with smaller airways. Depending upon the age of the child, younger infants are afebrile. Vomiting and diarrhea can occur at any age as the mucus from the nasal drainage enters the gastrointestinal tract.
Which electrolyte does the client with cystic fibrosis need in abundance? Potassium Sodium Chlorine Magnesium
Sodium Explanation: Dietary intake of sodium is encouraged due to increased sodium losses. Clients are especially encouraged to eat salty pretzels, potato chips, etc. during hot weather or when sodium losses are anticipated.
The nurse is caring for a child who has been admitted with a possible diagnosis of cystic fibrosis. Which laboratory/diagnostic tools would most likely be used to help determine the diagnosis of this child? Purified protein derivative test Sweat sodium chloride test Blood culture and sensitivity Pulmonary functions test
Sweat sodium chloride test Explanation: Sweat sodium chloride tests are used for determining the diagnosis of cystic fibrosis. Purified protein derivative tests are used to detect TB. Blood culture and sensitivity is done to determine the causative agent as well as the anti-infective needed to treat an infection. Pulmonary function tests are diagnostic tools for the child with asthma and indicate the amount of obstruction in the bronchial airways, especially in the smallest airways of the lungs.
The nurse is collecting data on a child admitted with a respiratory concern. The nurse notes that the child is anxious and sitting forward with the neck extended to breathe. The signs the nurse noted indicate the child likely has: epiglottitis. asthma. cystic fibrosis. tuberculosis (TB).
epiglottitis. Explanation: The child with epiglottitis is very anxious and prefers to breathe by sitting forward with the neck extended. Immediate emergency attention is necessary. The child with asthma would have wheezing and distress trying to breathe. The child with cystic fibrosis would not have respiratory distress unless ill with respiratory infection. The drooling, leaning forward, and appearing distressed are not manifestations of TB.
A 4-week-old infant is diagnosed with acute bronchiolitis. The parent states, "I do not know how the baby got this!" How should the nurse respond? "Do you have allergies in the family?" "Do any family members have history of asthma?" "Do you have air conditioning in your house?" "Has your infant been around any crowds?"
"Has your infant been around any crowds?" Explanation: Acute bronchiolitis is caused by a viral infection, most often, respiratory syncytial virus. Viruses are often spread between groups of people in close contact. Hereditary and environmental complications do not relate to this disorder.
The nurse notes a 3-year-old child is restless, has a respiratory rate of 55 breaths/minute, and has an oxygen saturation of 90%. Which action will the nurse take first? Notify the primary health care provider. Consult respiratory therapy. Apply oxygen via a facemask. Request a breathing treatment.
Apply oxygen via a facemask. Explanation: Oxygen is the most indicated treatment and is needed to increase low partial pressure of oxygen (PaO2) levels in the blood. The child is showing signs of hypoxemia and needs oxygen. The nurse will notify the health care provider after administering oxygen. Respiratory therapy and breathing treatments may be needed based on the child's response to oxygen.
The nurse is assigned four pediatric clients with diagnoses of acute bronchiolitis and acute interstitial pneumonia. When discussing the history of the disorder, the nurse anticipates which for the age of onset? "It is most often seen in premature newborns right after they are born." "Most children who have this are about 6 months old." "It usually occurs when children start school, around the age of 5." "Most children with this disorder are in their teens."
Most children who have this are about 6 months old." Explanation: Acute bronchiolitis (acute interstitial pneumonia) is most common during the first 6 months of life and is rarely seen after the age of 2 years.
Upon providing discharge instructions home after a tonsillectomy and adenoidectomy, which is most important? Provide acetaminophen for pain. Note any frequent swallowing. Allow the child an age-appropriate, quiet plan. Stress regular fluid consumption.
Note any frequent swallowing. Explanation: A complication of a tonsillectomy and adenoidectomy is bleeding. If the child is bleeding he or she must be brought to the emergency room immediately. To determine if a child is bleeding, the parents must assess for frequent swallowing. All of the other discharge instructions are appropriate, but noting any frequent swallowing is the priority.
The nurse is caring for a 6-week-old with symptoms of irritability, nasal stuffiness, difficulty drinking and occasional vomiting. Which assessment finding produces important information regarding the medical and nursing treatment plan? Obtain testing for respiratory syncytial virus. Screen for the "allergic salute." Obtain vital signs to determine an infection. Draw a blood count to see if the client is septic.
Obtain testing for respiratory syncytial virus. Explanation: The symptoms presented are of acute nasopharyngitis. Many times this is viral in nature and can be common in the very young from respiratory syncytial virus (RSV). RSV is tested by obtaining nasal secretions and sending to the lab. A 6-week-old may rub his/her face but is too young for the "allergic salute," which is done to relieve itching and open nasal pathways. Vital signs can be helpful to note the beginning of an infectious process.
What is the most common debilitating disease of childhood among those of European descent? Cystic fibrosis Asthma Pneumonia BPD
Cystic fibrosis Explanation: Cystic fibrosis is the most common debilitating disease of childhood among those of European descent. Medical advances in recent years have greatly increased the length and quality of life for affected children, with median age for survival being the late 30s.
The nurse makes the statement that if an older child inhales a foreign body, the inhaled object is more likely to be drawn into the right bronchus rather than the left. What is the basis for this statement? The left bronchus is shorter and wider than the right. The right bronchus is shorter and wider than the left. Both bronchi are the same size, but the left is more vertical than the right. The left bronchus is more vertical than the right.
The right bronchus is shorter and wider than the left. Explanation: In children older than 2 years, the right bronchus is shorter, wider, and more vertical than the left. If the child inhales a foreign body, it is more likely to be drawn into the right bronchus rather than the left.
Which test in a child with cystic fibrosis would help monitor airway function? Pulmonary function Bronchoprovocation Peak flow measurement Pulse oximetry
Pulmonary function Explanation: The pulmonary function tests help measure airway function, lung volumes, and gas exchange. Bronchoprovocation provokes bronchospasms to determine airway constriction. Peak flow measurement measures lung velocity. Pulse oximetry monitors blood level oxygen saturation.
A 5-year-old girl who was already admitted to the hospital for an unrelated condition suddenly becomes irritable, restless and anxious. These may be early signs of respiratory distress in a child if accompanied by: tachypnea. retractions. cyanosis. clubbing of fingers
tachypnea. Explanation: Restlessness, irritability, and anxiety result from difficulty in securing adequate oxygen. These might be very early signs of respiratory distress, especially if accompanied by tachypnea (an increased respiratory rate). Retractions can be a sign of airway obstruction but occur more commonly in newborns and infants than in older children. Cyanosis (a blue tinge to the skin) indicates hypoxia, which may be a sign of airway obstruction but would not be the first. Children with chronic respiratory illnesses often develop clubbing of the fingers, a change in the angle between the fingernail and nailbed because of increased capillary growth in the fingertips. Clubbing would not occur in an acute airway obstruction, as is indicated in the scenario above.
A child with asthma has been monitoring his peak expiratory flow rate (PEFR) and has been maintaining it within 90% of his personal best. Today, the child is experiencing symptoms and his PEFR is at 40% of his personal best. The child's mother calls the office and asks the nurse what she should do. What would the nurse instruct the mother to do first? "Have him use his short-acting bronchodilator right away." "You need to take him to the emergency department right away." "Continue to watch his PEFR readings and call back if they go below 40%." "Have him use his low-dose steroid inhaler now and again in 15 minutes."
"Have him use his short-acting bronchodilator right away." Explanation: The child's symptoms and drop in PEFR suggest a medical alert or "red" situation, indicating the need for the short-acting bronchodilator and then a trip to the office or emergency department. The child should use his short-acting bronchodilator first and then go to the physician's or nurse practitioner's office or emergency room. Waiting for a greater drop in his PEFR readings would be inappropriate because the child is experiencing an acute condition that warrants immediate attention. The child is experiencing an acute situation and requires immediate attention. A low-dose steroid inhaler would not be appropriate because it would not help his bronchospasm.
The pediatric unit has multiple clients experiencing upper respiratory system complications. Which pediatric client is at the highest risk for respiratory distress? 3-year-old child with croup 11-month-old infant with nasopharyngitis 2-year-old child with epiglottitis 16-year-old adolescent with asthma
2-year-old child with epiglottitis Explanation: Epiglottitis is a medical emergency due to the swelling of the epiglottis covering the larynx. This client needs frequent assessment for respiratory distress, especially since young children have smaller, more compliant airways. The 3-year-old child has more developed respiratory passages than a 2-year-old child, and although croup may cause respiratory distress, the likelihood of airway obstruction is lower when compared to epiglottitis. The 11-month-old infant has a common cold, typically from a virus. The 16-year-old adolescent with asthma has fully developed respiratory airways, which are less likely to be obstructed.
A 3-year-old child with asthma and a respiratory tract infection is prescribed an antibiotic and a bronchodilator. The nurse notes the following during assessment: oral temperature 100.2°F (37.9°C), respirations 52 breaths/minute, heart rate 90 beats/minute, O2 saturation 95% on room air. Which action will the nurse take first? Administer the bronchodilator via a nebulizer. Give the antibiotic as prescribed. Apply oxygen at 2 liters via a nasal cannula. Apply a cardiac monitor to the child.
Administer the bronchodilator via a nebulizer. Explanation: The nurse would first administer the bronchodilator to open the child's airway and facilitate breathing. Once the airway was open, the nurse could administer oxygen, if indicated. At this time, the child's saturation level is normal but it should be monitored. The nurse would then administer the antibiotic medication. The heart rate is within normal range for a child of this age (65 to 110 beats/minute); therefore, a cardiac monitor is not needed at this time.
When caring for a child with acute bronchiolitis, which nursing interventions should be included in the plan of care? Select all that apply. Encourage fluids. Administer oxygen. Suction the nose. Administer antibiotics. Follow contact precautions. Encourage activity.
Encourage fluids. Administer oxygen. Suction the nose. Follow contact precautions. The child is treated with nasal suctioning, rest, and increased fluids. Humidified oxygen may be administered via a nasal cannula, face mask, or an oxyhood (a clear plastic hood placed over the infant's head) if needed. Antibiotics are not prescribed because the causative organism is a virus. IV fluids often are administered to ensure an adequate intake and to permit the infant to rest. The hospitalized child is placed on contact transmission precautions to prevent the spread of infection.
The nurse is administering medications to a child with cystic fibrosis. Which method would the nurse most likely use to give medications to treat the pancreatic involvement seen in this disease? Open capsule and sprinkle on food. Shake inhaler and hold close to mouth. Draw up in syringe and administer subcutaneously. Pour in medication cup and have the child drink.
Open capsule and sprinkle on food. Explanation: Pancreatic enzymes should be administered at all meals and snacks to promote adequate digestion and absorption of nutrients. They are supplied in capsule form. For the infant and young child, they can be opened and sprinkled on foods such cereal, pudding, or applesauce. They also can be swallowed whole. They are not supplied in liquid form, so the child could not take them in a medication cup. They are not supplied for injection or inhalation, only oral use.
x The nurse caring for a school-aged client with cystic fibrosis aims to have the client meet the goal of adequate nutritional intake to compensate for decreased absorption of nutrients. What is the best indication that this is met? The client has gained weight from last visit. The client is on the honor roll at school. The client verbalizes being full at the end of meals. The client is within the 20th percentile for height and weight.
The client is within the 20th percentile for height and weight. Explanation: The client demonstrates adequate nutritional intake to compensate for decrease absorption of nutrients by remaining within normal limits on the growth chart and in the 20th percentile. A growth chart displays long-term trends in growth, making that method of assessment preferred over one visit. Intellectually, there are no deficits in a school-aged child with cystic fibrosis. Subjective data of being full at the end of meals is not an indicator of nutrients being absorbed.
