Chapter 40: Nursing Care of the Child With an Alteration in Gas Exchange/Respiratory Disorder

The nurse is caring for a 10-year-old girl with cystic fibrosis who receives pancreatic enzymes. Which comment by a parent demonstrates understanding of the instructions regarding the medication?

"I should give the enzymes before each meal or snack." Explanation: The enzymes are necessary for appropriate digestion and absorption of food and nutrients. There is no interaction between enzymes and antibiotics. Large, malodorous stools are a sign of no pancreatic enzyme activity. Pancreatic enzymes must be given each time the child eats, usually in smaller doses for snacks than for meals.

A 4-year-old with bronchiolitis has been admitted to the hospital with respiratory compromise. The father asks the nurse why the physician won't prescribe an antibiotic, "My child just keeps getting worse." What is the best response by the nurse?

"Bronchiolitis is almost always caused by the respiratory syncytial virus (RSV). Unfortunately, antibiotics don't work on viruses." Bronchiolitis is an acute inflammatory process of the bronchioles and small bronchi. Nearly always caused by a viral pathogen, respiratory syncytial virus (RSV) accounts for the majority of cases of bronchiolitis; therefore, antibiotic therapy is not warranted.

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?

"Exposure to second- or third-hand smoke increases the risk for developing RSV." Explanation: An infant exposed to second- or third-hand 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.

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?

"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.

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." 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.

An 8-year-old girl presents with drooling and a complaint of painful swallowing. She has a high fever and is lethargic. On examination the nurse sees that her palatine tonsils are bright red and swollen. The girl's mother says that she has never had these symptoms before. A throat culture indicates a streptococcus infection. What is the course of treatment that the nurse would expect in this situation?

Antipyretic, analgesic, and antibiotic Explanation: These symptoms are consistent with bacterial tonsillitis. Therapy for bacterial tonsillitis includes an antipyretic for fever, an analgesic for pain, and a full 7- to 10-day course of an antibiotic such as penicillin or amoxicillin. If the cause is viral, no therapy other than comfort or fever reduction strategies is necessary. Tonsillectomy is removal of the palatine tonsils. Adenoidectomy is removal of the pharyngeal tonsils. In the past, tonsillectomy was recommended for children after an episode of tonsillitis. This is no longer recommended as tonsillar tissue is an important component of the immune system.

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?

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.

Pancreatic enzymes are part of the treatment in cystic fibrosis. When should the nurse administer the enzymes?

Before meals and snacks with milk Explanation: Enzymes should be administered before all meals and snacks to help in normal absorption of nutrients from the food. The other choices do not promote absorption of foods or are not taken with food.

The nurse is teaching the caregivers of a child with cystic fibrosis. What is most important for the nurse to teach this family?

Encourage everyone in the family to use good handwashing techniques. Explanation: The child with cystic fibrosis has low resistance, especially to respiratory infections. For this reason, take care to protect the child from any exposure to infectious organisms. Good handwashing techniques should be practiced by the whole family; teach the child and family the importance of this first line of defense. Practice and teach other good hygiene habits.

What measure at home could help a child with an upper respiratory infection breathe more easily?

Increasing room humidity Explanation: A moist environment helps prevent respiratory secretions from drying and becoming difficult to raise.

What statement is the most accurate regarding the structure and function of the newborn's respiratory system?

Most infants are nasal breathers rather than mouth breathers. Explanation: Newborns are obligatory nose breathers until at least 4 weeks of age. The diameter of the infant and child's trachea is about the size of the child's little finger. The respiratory tract grows and changes until the child is about 12 years of age. During the first 5 years of life, infants and young children have larger tongues in proportion to their mouths.

Which nursing diagnosis would best apply to a child with allergic rhinitis?

Pain related to sinus edema and headache Explanation: Many children with allergic rhinitis develop sinus headaches from edema of the upper airway. In younger children the maxillary and ethmoid sinuses are involved. In children aged 10 years and older the frontal sinuses are also involved. The pain comes from mucosal swelling, decreased ciliary movement and a thickened nasal discharge. Nosebleeds are not common with either allergic rhinitis or sinusitis nor are either of these inherited. The eustachian tubes would cause symptoms of otitis, not of the nasal passage.

A group of nurses is reviewing the diagnosis of cystic fibrosis. With regard to the effect of this disease on the body, which parts of the body (besides the lungs) are most affected by this disease?

Pancreas and liver Explanation: The major organs affected are the lungs, pancreas, and liver. The brain, spinal cord, heart, blood vessels, kidney and bladder are not the most affected organs.

A pediatric client is having difficulty breathing. Which nursing intervention is appropriate for this client?

Provide oxygen as needed to maintain oxygen saturation above 93%. Explanation: The nurse would provide oxygen to increase oxygen saturation as needed for this child. A decrease in oxygen saturation will cause the child to have an increase in the work of breathing. The positioning does not promote an open airway. Having family members leave the room could increase the child's anxiety, which would worsen the respiratory status. Continuing to monitor the child provides no assistance or relief.

A worried mother calls the nurse and tells her that her son has developed a horrible croup cough and is having trouble breathing. What would be the best intervention for the nurse to recommend to the mother?

Run a hot shower to fill the bathroom with steam and have the boy stay there. Explanation: One emergency method of relieving croup symptoms is for a parent to run the shower or hot water tap in a bathroom until the room fills with steam, then keep the child in this warm, moist environment as this relaxes the airway tissues and widens the bronchi lumens. If this does not relieve symptoms, parents should bring the child to an emergency department for further evaluation and care. Caution parents not to give cough syrup routinely to children as many produce little effect and the risk of overdose, incorrect dosing, and adverse events is greater than the benefit of the syrup. An analgesic might help alleviate pain due to inflammation and irritation of the throat from coughing, but it is not the priority intervention in this case. Drinking would likely be painful for this child and would not provide lasting benefit.

The nurse is assessing the site of a client's Mantoux skin test. The client is HIV positive. The nurse notes the induration to be 10 mm. Which action will the nurse take next?

Schedule the client for a chest x-ray. Explanation: Diagnosis of tuberculosis (TB) is confirmed with a positive Mantoux test. An induration of 5 mm is considered positive for clients with HIV. If a client's Mantoux test is positive, the client is next scheduled for a chest x-ray to look for lung changes related to TB, or for a sputum smear test. These tests are done to determine if a client has latent or active TB, which will then determine the course of action for the client. The nurse will document the results; however, documentation is not priority. There is no need to ask about exposure since the test results indicate exposure. The client with active TB will be placed on airborne precautions.

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?

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 trying to pick a method to teach a 4-year-old with cystic fibrosis a good way to exercise her lungs. Which would be the developmentally correct strategy to help this client?

Teach the client to blow bubbles. Explanation: A helpful exercise for the client would be to blow bubbles, a horn, or a pinwheel. This would help her exercise her lung capacity and is age-appropriate for early childhood. The other exercises are all normal activities for school-aged children.

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'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 is taking a respiratory history of a newly admitted child. While documenting the symptoms the child has, what other item is important to document when taking a history on an altered respiratory status?

The triggers in the environment Explanation: When assessing a respiratory history, it is very important for the nurse to find out what in the environment worsens the child's symptoms. These are called "triggers." The other choices would be part of a general health history.

The nurse at a camp for children with asthma is teaching these children about the medications they are taking and how to properly take them. The nurse recognizes that many medications used on a daily basis for the treatment of asthma are given by which method?

Using a nebulizer Explanation: Many of these drugs used in the treatment of asthma can be given either by a nebulizer (tube attached to a wall unit or cylinder that delivers moist air via a face mask) or a metered-dose inhaler ([MDI], which is a hand-held plastic device that delivers a premeasured dose). Emergency medications are given intravenously. Most children do not have a gastrostomy tube, and medications sprinkled on foods are given with cystic fibrosis.

The student nurse is collecting data on a child diagnosed with cystic fibrosis and notes the child has a barrel chest and clubbing of the fingers. In explaining this manifestation of the disease, the staff nurse explains the cause of this symptom to be:

chronic lack of oxygen. Explanation: In the child with cystic fibrosis the development of a barrel chest and clubbing of fingers indicate chronic lack of oxygen. Impaired digestive activity may occur due to a lack of pancreatic enzymes. The high sodium concentration makes the child taste salty, but is not related to the barrel chest and clubbing of the fingers. Respiratory issues are a concern, but the barrel chest and clubbing of the fingers are not because of the child's respiratory capacity.

The health care provider has prescribed beclomethasone for long term control of asthma. The nurse is most correct to advise the client that beclomethasone is a:

corticosteroid. Explanation: Beclomethasone is a corticosteroid prescribed for long-term asthma control. Mast cell stabilizers help to decrease bronchospasm and mucous membrane inflammation. A xanthine derivative such as theophylline is a time-released bronchodilator. Leukotriene inhibitors help with bronchodilation and decrease airway edema.

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. 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.

What is a symptom of bacterial pharyngitis?

fever Explanation: Bacterial pharyngitis is most often caused by group A streptococcus. Fever is a symptom of bacterial pharyngitis. Other symptoms are an elevated WBC count, abrupt onset, headache, sore throat, abdominal discomfort, enlargement of tonsils, and firm cervical lymph nodes. It must be treated with an antibiotic. Penicillin is the drug of choice. Symptoms of rhinitis, a normal WBC count, and slow onset are indicative of viral pharyngitis.

A nurse is providing supplemental oxygen therapy to a young child. Based on the nurse's understanding of oxygen delivery methods, what would the nurse expect to be used to deliver the highest concentration of oxygen to the child?

nonrebreather (face) mask Explanation: A nonrebreather (face) mask provides 95% oxygen concentration. An oxygen hood provides up to 80% to 90% oxygen concentration. This delivery method is used only for infants. A partial rebreather mask provides 50% to 60% oxygen concentration. A Venturi mask provides 24% to 50% oxygen concentration.

The nurse is teaching a child and their parents how best to manage the child's asthma. Which piece of equipment will be most helpful in determining the status of this child's airway?

peak flow meter Explanation: The peak flow meter provides the most reliable early sign of an asthma episode. Most episodes begin gradually, and a drop in peak flow can alert the child and parents to begin medications before symptoms actually are noticeable. A nebulizer and inhaler treat symptoms. An incentive spirometer is used for lung expansion, especially after surgery.

The nurse identifies a nursing diagnosis of Ineffective airway clearance related to inflammation and copious thick secretions. What action is the priority?

suctioning secretions from the airway Explanation: The priority intervention is suctioning secretions to provide a patent airway. Administering oxygen as ordered, monitoring oxygen saturation by pulse oximeter, and administering analgesics as ordered would be secondary interventions.

If there is a foreign body in the larynx, how will the client present?

with stridor Explanation: A foreign body can be either solid or liquid and it can lodge in the upper or lower airways. If a child has symptoms of cough, wheezing and/or stridor, it is an indication the foreign body is obstructing the upper airway. The child with a foreign body obstruction is anxious, has difficulty talking, and may be drooling. Edema of the airways may have occurred but generalized edema is not present

The nurse is mentoring a new graduate who is completing a respiratory assessment on a client with suspected epiglottitis. Which action by the new graduate would require clarification?

Assessment of the nasopharynx Explanation: Assessment of the nasopharynx, especially with a tongue blade, is contraindicated as it may initiate a gag reflex and complete obstruction may occur. The mentoring nurse would advise the nursing student to listen to the quality of the client's respiration to document status. Humidified air, continuous pulse oximetry and parenteral antibiotic administration are treatment options for the client with suspected epiglottitis.

The nurse is caring for a 14-month-old boy with cystic fibrosis. Which sign of ineffective family coping requires urgent and immediate intervention?

Compliance with therapy is diminished. Explanation: Until the family adjusts to the demands of the disease, they can become overwhelmed and exhausted, leading to noncompliance, resulting in worsening of symptoms. Typical challenges to the family are becoming overvigilant, the child feeling fearful and isolated, and the siblings being jealous or worried, but these are not a priority over the noncompliance.

The nurse is taking a health history for a 3-year-old girl suspected of having pneumonia who presents with a fever, chest pain, and cough. Which information places the child at risk for pneumonia?

The child attends day care. Explanation: Attending day care is a known risk factor for pneumonia. Being a triplet is a factor for bronchiolitis. Prematurity rather than postmaturity is a risk factor for pneumonia. Diabetes is a risk factor for influenza.

After teaching the parents of an 8-year-old girl with asthma about common allergens their child should avoid, the nurse determines that the parents need additional teaching when they identify what as a common allergen for asthma?

shellfish Explanation: Eating shellfish is not a typical asthma trigger. Allergic reactions can occur with shellfish, but usually not an exacerbation of asthma. Indoor molds, pet dander, and dust mites are common asthma triggers.

The nurse is assessing a 7-year-old boy with pharyngitis. What assessment finding would suggest the child has developed a peritonsillar abscess?

shifting uvula Explanation: Peritonsillar abscess may be noted by asymmetric swelling of the tonsils and shifting of the uvula to one side. Difficulty swallowing, sore throat, and headache are consistent with pharyngitis, as is the rash, which would be fine, red, and sandpaper-like (called scarlatiniform) but do not indicate a peritonsillar abscess.

The nurse is caring for a 5-year-old client and notes respiratory rate of 45 breaths per minute, blood pressure 100/70 mm Hg, heart rate 115, temperature 101°F (38.3°C), and oxygen saturation 86%. Which diagnostic test is priority for the nurse to complete?

Arterial blood gas (ABG) Explanation: The most useful diagnostic test in respiratory distress is an ABG. Knowing normal blood gas values for children is very important for evaluation and proper treatment. A CBC is a blood test used to test for disorders including anemia, infection, and leukemia. An EEG is a test used to find problems related to electrical activity of the brain. A pulmonary function test is performed to evaluate the respiratory system. Based on the findings, the child is experiencing respiratory distress and has an elevated temperature. Airway and breathing are priority over an elevated temperature. The child's blood pressure is within normal range for this age.

The nurse is caring for a child who has been admitted with a diagnosis of asthma. What laboratory/diagnostic tool would likely have been used for this child?

Pulmonary functions test Explanation: Pulmonary function tests are valuable 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. Purified protein derivative tests are used to detect TB. Sweat sodium chloride tests are used for determining the diagnosis of cystic fibrosis. Blood culture and sensitivity is done to determine the causative agent as well as the anti-infective needed to treat an infection.

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 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.

The nurse has assessed a 6-year-old child as having respiratory distress due to swelling of the epiglottis and surrounding structures. Which signs and symptoms would support this assessment?

The child is in tripod position. Explanation: Inflammation and swelling of the epiglottis and surrounding structures are common in children ages 2 to 7 years. The child will attempt to improve his/her airway by sitting forward and extending the neck forward with the jaw up, in a "sniffing position" (tripod position). Being pale, vomiting, and having elevated patches on the skin are not associated with epiglottis. Stridor, tachycardia, and the rapid onset are classical signs of epiglottitis.

The nurse is admitting a child who is experiencing an asthma attack. Which clinical manifestation would likely be noted in this child?

Wheezing Explanation: The onset of an attack can be very abrupt or can progress over several days, as evidenced by a dry hacking cough, wheezing (the sound of expired air being pushed through obstructed bronchioles), and difficulty breathing. Chest retractions can be seen when there is severe respiratory distress. Hoarseness is most commonly seen with illness such as laryngitis. Circumoral cyanosis is seen with children with poor perfusion, such as a child with a congenital heart defect.

A nurse is assessing a 3-month-old infant during a pediatric clinic visit. The nurse believes the infant is demonstrating mild manifestations of respiratory distress. Which clinical manifestation(s) leads the nurse to suspect this distress? Select all that apply.

decreased intake nasal congestion fussiness Mild signs of respiratory distress in an infant include fussiness, nasal congestion, and no interest in feeding. Moderate distress presents with nasal flaring, grunting, retractions, mild tachypnea and mild tachycardia. Signs of severe respiratory distress included cyanosis, diaphoresis, dehydration, severe tachypnea and severe tachycardia, as well as exhaustion from respiration effort.

Which education will the nurse provide to parents of a 1-month-old infant recently diagnosed with congenital laryngomalacia? Select all that apply.

"Most children improve as the cartilage becomes stronger." "Your infant may need to take frequent breaks when feeding." "Seek medical care if you notice signs of a respiratory illness." Congenital laryngomalacia results when an infant's laryngeal structure is weaker and more flexible than normal. There is no treatment for congenital laryngomalacia, besides slow feedings and frequent rest periods. For this reason, parents would not need to bring the infant back if there was no improvement within 1 week. Most children will outgrow this disorder around 1 year of age as the cartilage of the larynx becomes stronger. Parents should be advised to seek medical care at the first signs of an upper respiratory illness because the infant could develop a more severe laryngeal collapse.

The nurse is administering 2 puffs of an albuterol sulfate inhaler to a 4-year-old. Which side effect would the nurse instruct the parent to most likely expect?

Increased heart rate and restlessness Explanation: The nurse instructs the parents on the side effects of the bronchodilator, albuterol sulfate. The side effect of this medication is restlessness, anxiety, fear, palpitations, and tremors. It is important for the parents to realize this so they understand the actions of the 4-year-old. Once the bronchial tree is open, cough is decreased but mucus expectoration could increase. The medication does not cause drowsiness.

A school-aged child develops a nosebleed (epistaxis). Which action should the nurse take?

Sit the child upright and apply pressure to the sides of the nose. Explanation: Epistaxis occurs more frequently in children than adolescents. The bleeding occurs from the anterior portion of the septum. To stop the bleeding, have the child sit up and lean forward. Apply continuous pressure to the anterior portion of the nose by pinching it closed. Ice may be used on the bridge of the nose. Having the child lie flat increases the risk of aspiration from the blood in the back of the throat. Putting pressure on the forehead will not stop nasal bleeding. Lying on the side and putting pressure on the bridge of the nose will not effectively put pressure on the bleeding vessels to cause them to coagulate and stop bleeding.

The nurse is caring for a child with a history of cystic fibrosis (CF). Which finding will the nurse report to the primary health care provider?

Wheezing Explanation: The nurse would report wheezing, as this indicates respiratory distress. Clubbing occurs with chronic respiratory illness. It is the result of increased capillary growth as the body attempts to supply more oxygen to distal body parts. Barrel chest refers to the shape the chest takes on in chronic respiratory illness. It takes the shape as chronically the lungs fill with air but are unable to fully expel the air. Delayed puberty is common in clients with cystic fibrosis and does not require reporting at this time.

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:

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 6-year-old child was diagnosed as having streptococcal pharyngitis. At the follow-up visit, the nurse will assess the child for which potential complication?

development of rheumatic fever Explanation: The Group A strain of streptococci causing streptococcal pharyngitis can cause a hypersensitivity reaction that results in either rheumatic fever or glomerulonephritis. Swollen lymph nodes obstructing the airway would occur during the illness, not afterward. They would have been addressed at an emergency visit, rather than at the routine follow-up visit. The organism will not affect the teeth. Nephrosis or nephrotic syndrome relates to increased edema and protein, not the infection of the kidney (glomerulonephritis).

The nurse is teaching the parents about medications for their 9-year-old boy who has a respiratory disorder. The nurse would be alert for an increased need for medications if the child was exposed to second-hand smoke and has which condition?

Asthma Explanation: In general, it is important for any child with a respiratory illness to avoid second-hand smoke. However, exposure to second-hand smoke increases the need for medications in children with asthma and increases the frequency of asthma exacerbations. In general, it is important for any child with a respiratory illness to avoid second-hand smoke. However, the presence of smoke does not increase the medication needs for children with a cold. In general, it is important for any child with a respiratory illness to avoid second-hand smoke. However, the presence of smoke does not increase the medication needs for children with pneumonia. In general, it is important for any child with a respiratory illness to avoid second-hand smoke. However, the presence of smoke does not increase the medication needs for children with allergic rhinitis (hay fever).

The mother of a child with asthma tells the nurse that she occasionally gives her child the steroid medicine she takes for her rheumatoid arthritis when the child has a "flare-up" of asthma. "It's easier than going to the hospital or doctor every time a flare-up happens," the mother says. What is the best response by the nurse?

"I'm sure it must be difficult to cope with the flare-ups, but there are many side effects from steroid use and the physician needs to monitor your child's asthma symptoms." Explanation: Showing empathy for the parent is important when explaining the possibility of the steroid's side effects and the importance of the physician monitoring the child's asthma. Just listing all of the side effects of the steroid is not therapeutic communication and doesn't address the need for the child to be seen by the physician. Scolding the parent by telling her that she should never give her child her medication does not encourage good rapport. Giving the child the mother's medication even "occasionally" is not advisable.

The nurse working at the child community clinic must administer the influenza vaccine to the high-risk children first. Which child would she choose first?

23-month-old client who had heart surgery as an infant for a defect Explanation: Children who are considered high risk and could benefit from the influenza vaccine are: immunocompromised have a chronic pulmonary disease have had a congenital abnormality chronic renal or metabolic disease sickle-cell disease HIV any type of neurological disorder (seizures) The other choices would be considered normal and the child is not at high risk.

A child presents to the health clinic with a temperature of 101.8°F (38.8°C), dysphagia, headache, and a sore, erythematous throat. Which collaborative intervention will the nurse complete first?

Obtain a throat culture. Explanation: A child presenting with fever, dysphagia, headache, and a sore, erythematous throat may have viral or bacterial pharyngitis. The nurse's first action should be to obtain a throat culture to determine if the child has a bacterial or viral infection. If the throat culture is negative, the child will not require antibiotics. If the culture is positive, the child will need antibiotics. Saltwater gargles will help relieve pain, but this is not a priority. Children with streptococcal pharyngitis may develop a sandpaper rash, but this information alone is not conclusive, and a throat culture should be obtained prior to administering antibiotics.

The school nurse is caring for a 12-year-old boy with a bloody nose. Which action would be most appropriate for the nurse to do?

Seat the child leaning forward and pinch the anterior portion of the nose closed. Explanation: The child should sit up and lean forward. Apply continuous pressure to the anterior portion of the nose by pinching it closed. The bleeding usually stops within 10 to 15 minutes. Ice or a cold cloth on the bridge of the nose may help, but pressure will stop the bleeding. Lying down or tipping the head back may allow aspiration of the blood and should be avoided.

The nurse sees a 3-year-old child in the ambulatory setting for localized wheezing on auscultation. Which statement by the parent would be most important to report to the health care provider?

The child was eating peanuts yesterday. Explanation: Aspiration can cause airway mucosal inflammation. When aspiration from a small object occurs, the child may cough and gasp for a few seconds to a few minutes. Following that, the child may not be symptomatic for a day or longer. The aspiration of a foreign body may mimic an asthma attack, but an asthma attack would have generalized wheezing. Localized wheezing suggests only a small portion of a lung is involved, such as occurs following aspiration. Allergic situations cause early symptoms such as rash development and are generally not genetic or inherited in nature. The US Centers for Disease Control and Prevention recommends children receive pneumococcal vaccine series before 2 years of age, usually at 2, 4, and 6 months.

The nurse has assessed four clients. Which assessment finding warrants immediate action?

1-week old newborn with nasal congestion Explanation: Until 4 weeks of age, newborns are obligatory nose breathers and breathe only through their mouths when they are crying. The newborn cannot automatically open the mouth to breathe if the nose is obstructed; therefore, a newborn with nasal congestion needs immediate action. Also, the newborn and young infant have very small nasal passages, so when excess mucus is present, airway obstruction is more likely. Mouth breathing may occur when a large amount of nasal congestion is present. Although this finding is abnormal and warrants follow up, in a 6-year-old child this finding does not warrant immediate action. Through early school-age, children tend to have enlarged tonsillar and adenoidal tissue even in the absence of illness; therefore, this finding is normal in a 4-year-old child and does not warrant immediate follow up. The frontal sinuses and the sphenoid sinuses develop by age 6 to 8 years; therefore a 10-year-old child may develop a sinus infection. Although these symptoms warrant follow up, immediate action is not necessary.

An 8-year-old with cystic fibrosis has had a noted decline on the growth chart. Which nursing intervention is best for maintaining adequate nutrition?

Encourage high calorie, high protein snacks. Explanation: The best nursing intervention is a high calorie, high protein snack. Calories can be obtained from non-nutritious foods. It is not only that the client needs calories for energy, but nutrition needs to be present. Pancreatic enzymes aid in digestion so they need to be available for foods; thus they are given prior to ingestion. Sodium is encouraged due to the high sodium loss.

During a class for caregivers of children with asthma, a caregiver asks the nurse the following question when medications are being discussed. "They told me about a plastic device my child can hold in his a hand which will give him a premeasured and exact amount of his corticosteroid." The nurse recognizes that the caregiver is most likely referring to which device?

Metered-dose inhaler Explanation: In the treatment of asthma, corticosteroids are most often delivered by metered-dose inhaler ([MDI], which is a hand-held plastic device that delivers a premeasured dose). The medication cup and needleless syringe may deliver PO medications, but most often corticosteroids are not given PO in the treatment of asthma, and those would not be premeasured and an exact dosage like a metered-dose inhaler would be. Corticosteroids are not administered by nebulizer.

The pediatric unit has multiple clients experiencing upper respiratory system complications. Which pediatric client is at the highest risk for respiratory distress?

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 4-year-old child has been admitted to the hospital with a diagnosis of pneumococcal pneumonia. The parents are extremely distraught over the child's condition and the fact that the child has not wanted to eat anything for the past 2 days. Which nursing approach would be most important to take to help alleviate the high anxiety level of the parents?

Allow the parents to remain with the child as much as possible. Explanation: Pneumonia may be caused by many reasons: bacteria, viruses, fungus, and aspiration. If the child has mild symptoms (no respiratory distress) he or she may be treated at home. Hospitalization is required if the child has oxygen requirements, shows signs of respiratory distress, has poor oral intake, and has lethargy. Oxygen supplementation, IV fluids, and antibiotics will be necessary. It is very frightening for the parents to see their child so ill, and it is very frightening for the child to be so sick and be in a strange environment. The parents should be allowed to remain with their child at all times and their concerns should be addressed. The nurse should explain that not eating is part of the illness, but the child is being hydrated with IV fluids and will start eating as the illness improves. Telling the parents the child is receiving the best care possible does not address their concern of not eating. Parents should be educated on all aspects of the child's condition and prognosis.

What is a complication of cystic fibrosis?

pneumothorax Explanation: Cystic fibrosis (CF) is a genetic disorder causing thickened tenacious secretions of the sweat glands, gastrointestinal tract, pancreas, respiratory tract and exocrine tissues. The treatment is aimed at minimizing pulmonary complications, maximizing lung function, preventing infection, and facilitating growth. A pneumothorax is a complication of CF. A rupture of the subpleural blebs through the visceral pleura takes place. There is also a high reoccurrence rate and incidence increases with age. Crohn disease is a gastrointestinal disorder that is not associated with cystic fibrosis. Urinary tract infection and kidney disease are also not associated with CF. Most of the problems and complications associated with CF relate to the respiratory system, the gastrointestinal system, and infectious disorders.