Emergency Practice Questions
A 3 year old arrives to the ER. The child has a temperature of 102.4 F, respiratory rate of 45, and is agitated. The child is diagnosed with epiglottitis. You note the child is sitting up, positioned forward with chin in the air and the tongue is protruding with the mouth open. Which nursing intervention below is NOT appropriate for this patient? A. Assist the patient in a supine position. B. Keep the child on the parent's lap during treatments. C. Keep the child nothing by mouth. D. Avoid taking a temperature on the patient orally.
The answer is A. Allow the child to be in a position that allows them to breathe and be comfortable. The child is in the tripod position, which is a common finding with epiglottis. Placing the child in the supine position is contraindicated because it impedes respiratory effort. A nursing goal is to keep the child calm (avoid things that cause the child to cry because this can affect the airway since the epiglottis is inflamed). So, keeping the child in the parent's lap during treatments is appropriate. In addition, NEVER place anything in the patient's mouth due to the risk of causing spasms which will further constrict the airway.
The nurse admits a client diagnosed with moderate hypothermia. Which finding should the nurse expect to observe during the physical assessment? 1. Flushing 2. Tachycardia 3. Absence of shivering 4. Tachypnea
3. Absence of shivering Flushing, tachypnea, and tachycardia are indicative of hyperthermia. Absence of shivering occurs when a client has reached at least moderate hypothermia.
A nurse working at a children's hospital receives report on four patients who were just admitted to the unit within the past hour. Which nurse should the nurse assess first? 1) A 9-month-old infant who has been vomiting for the past 12 hours who has a fever of 100.3. 2) A 4-month-old who is resting quietly right now with reports of jelly-like stools and severe pain for the past 6 hours. 3) A 2-year-old who with a fractured femur who was medicated 30 minutes ago for pain. 4) A 3-month-old who has passed runny stools frequently overnight with sunken anterior and posterior fontanelles.
2) Jelly-like stools and severe pain indicate intussusception, and this is a medical emergency. Afterwards, the nurse should assess the child with sunken fontanelles, as this indicates severe dehydration.
From an assessment of vital signs, the nurse learns that a client has a body temperature of 35.7°C (96.2°F). Which action should the nurse take? Select all that apply. 1. Provide oral hygiene. 2. Provide warm oral fluids. 3. Cover with a warmed blanket. 4. Administer a tepid sponge bath. 5. Cover the head with a cap.
2. Provide warm oral fluids. 3. Cover with a warmed blanket. 5. Cover the head with a cap.
The nurse is performing cardiopulmonary resuscitation (CPR) on an adult client. When performing chest compressions, the nurse should depress the sternum by how many inch(es)? 1. 3/4 inch 2. 1 inch 3. 2 inches 4. 3 inches
3. When performing CPR on an adult client, the sternum is depressed 2 inches. The depth for the adult and the child is 2 inches whereas for the infant is 1 1/2 inches.
You're assessing a 4 year old with epiglottitis who just arrived to the pediatric clinic. The child is drooling and has a respiratory rate of 45 breaths per minute. In addition, the child is becoming increasingly apprehensive. Which findings below exhibited by the patient represents an acute upper airway obstruction that requires IMMEDIATE treatment? Select All That Apply A. Stridor B. Cyanosis C. Chest retractions D. Nasal flaring
All the answers are correct. All these findings represent an upper airway obstruction and require immediate treatment.
Which statement is correct regarding the role of the epiglottis? A. This structure prevents food from entering the nasopharynx. B. The epiglottis helps with vocal cord vibration. C. After swallowing this structure moves downward to prevent swallowed contents from entering the trachea. D. The epiglottis is found in between the vocal folds.
The answer is C. Option A is wrong because this is the role of the uvula (NOT epiglottis). Option B is wrong because this is the role of the GLOTTIS (not epiglottis). Option D is where the glottis is found (not epiglottis). The epiglottis is found on the inside of the thyroid cartilage and is at the back of the tongue.
A 5 year old with acute epiglottitis is intubated for airway management. As the nurse you know that all of the following can be prescribed as treatment for this condition EXCEPT? A. Intravenous fluids B. Antipyretics C. Corticosteroids D. Cough suppressants
The answer is D. A cough is usually absent in this condition, which is present in croup (laryngotracheobronchitis). Therefore, cough suppressants are not usually ordered for this condition because there is no cough.
Which is the nurse's best response to the parent of a child diagnosed with epiglottitis who asks what the treatment will be? 1. Complete a course of intravenous antibiotics. 2. Surgery to remove the tonsils. 3. 10 days of aerosolized ribavirin. 4. No intervention.
1 1. Epiglottitis is bacterial in nature and requires intravenous antibiotics. A 7- to 10-day course of oral antibiotics is usually ordered following the intravenous course of antibiotics. 2. Surgery is not the course of treatment for epiglottitis. Epiglottal swelling usually diminishes after 24 hours of intravenous antibiotics. 3. Ribavirin is an antiviral medication used to treat RSV. 4. Epiglottitis is a bacterial infection; a course of intravenous antibiotics is indicated. TEST-TAKING HINT: Understanding that epiglottitis is bacterial in nature will lead the test taker to choose the correct answer.
The nurse witnesses a neighbor's husband sustain a fall from the roof of his house. The nurse rushes to the victim and determines the need to open the airway. The nurse opens the airway in this victim by using which method? 1. Flexed position 2. Head tilt-chin lift 3. Jaw thrust maneuver 4. Modified head tilt-chin lift
3. If a neck injury is suspected, the jaw thrust maneuver is used to open the airway. the head tilt-chin lift maneuver produces hyperextension of the neck and could cause complications if a neck injury is present. A flexed position is an an inappropriate position for opening the airway.
The nurse observes an 18mo who has been admitted with respiratory tract infection who is drooling and sitting forward with an open mouth and has a protruding tongue. the nurse should first A. Position the child supine B. Call the rapid repsonse team C. Suction the airway D. Administer oxygen
B. The nurse should suspect epiglottitis in any young child with a respiratory infection who sits leaning forward with an open mouth and protruding tongue and is drooling. Epiglottitis is a medical emergency. The rapid response team should be notified to secure the airway. While waiting for the team, the child should remain sitting upright to facilitate breathing; complete obstruction may occur if the child is placed prone or becomes agitated. Therefore, it is important to avoid any procedures that upset the child such as suctioning or applying oxygen.
Select all the signs and symptoms that can present with epiglottitis? A. Slow onset B. Difficulty swallowing C. Drooling D. High Fever E. Barking cough F. Stridor G. Exudate on Tonsils H. Crackles
The answers are B, C, D, and F.
The parents of a 3 year old bring their child to the ER. The parents report the child suddenly developed a fever overnight and has had issues swallowing, which has led to excessive drooling. In addition, the parents explain that the child complains of sore throat, and it is hard to understand the child's speech because her voice is muffled. Based on this information, your next nursing actions will be? Select all that apply: A. Assess the child's temperature orally B. Obtain a throat culture C. Count the patient's respirations D. Assess the child's throat for tonsillar exudate E. Keep the child NPO
The answers are C and E. Based on the patient's signs and symptoms this may be a case of epiglottitis. Therefore, the nurse should NOT stick anything in the patient's mouth that could can a spasm (example: taking oral temperature, throat culture, using a tongue depressor etc.) and further block the airway.
The nurse receives a call from the mother of a 6-month-old who describes her child as alternately sleepy and fussy. She states that her infant vomited once this morning and had two episodes of diarrhea. The last episode contained mucus and a small amount of blood. She asks the nurse what she should do. Which is the nurse's best response? 1. "Your infant will need to have some tests in the emergency department to determine whether anything serious is going on." 2. "Try feeding your infant in about 30 minutes; in the event of repeat vomiting, bring the infant to the emergency department for some tests and intravenous rehydration." 3. "Many infants display these symptoms when they develop an allergy to the formula they are receiving; try switching to a soy-based formula." 4. "Do not worry about the blood and mucus in the stool; it is not unusual for infants to have blood in their stools because their intestines are more sensitive."
1 1. The infant is displaying signs of intussusception. This is an emergency that needs to be evaluated to prevent ischemia and perforation. 2. The mother should be told not to give the infant anything by mouth and bring the infant immediately to the emergency department. 3. Although similar symptoms may be seen among infants with allergies, a more serious illness must fi rst be ruled out. It is uncommon to see lethargy as a response to an allergy. 4. All bloody stools should be evaluated. TEST-TAKING HINT: The child is described as lethargic and is having diarrhea and vomiting. This child needs to be seen to rule out an intussusception. At the very least, the mother should be told to bring the child to the emergency department because the described signs could also be seen in severe dehydration. The test taker should be led to select answer 1.
Which child is in the greatest need of emergency medical treatment? 1. A 3-year-old who has a barky cough, is afebrile, and has mild intercostal retractions. 2. A 6-year-old who has high fever, no spontaneous cough, and frog-like croaking. 3. A 7-year-old who has abrupt onset of moderate respiratory distress, a mild fever, and a barky cough. 4. A 13-year-old who has a high fever, stridor, and purulent secretions.
2 1. This child has signs and symptoms of acute laryngitis and is not in a significant amount of distress. 2. This child has signs and symptoms of epiglottitis and should receive immediate emergency medical treatment. The patient has no spontaneous cough and has a frog-like croaking because of a signifi cant airway obstruction. 3. This child has signs and symptoms of LTB and is not in significant respiratory distress. 4. This child has signs and symptoms of bacterial tracheitis and should be treated with antibiotics but is not the patient in the most significant amount of distress. TEST-TAKING HINT: The test taker must accurately identify that the question is describing a child with epiglottitis. The test taker must also understand that epiglottitis is a pediatric emergency and can cause the child to have complete airway obstruction.
The nurse witnesses the collapse of a victim in her neighborhood and suspects cardiac arrest. Which action should the nurse take first? 1. Initiate rescue breathing 2. Begin giving chest compressions 3. Activate the emergency response system 4. Obtain an automated external defribillator
3. If a collapse is witnessed and the nurse suspects cardiac arrest, the nurse should first activate the emergency response system. Next, the nurse should obtain an automated external defibrillator, followed by initiation of cardiopulmonary resuscitation, beginning with chest compressions.
The nurse on the day shift walks into a client's room and finds the client unresponsive. The client is not breathing and does not have a pulse, and the nurse immediately calls out for help. Which is the next nursing action? 1. Open the airway 2. Give the client oxygen 3. Start chest compressions 4. Ventilate with a mouth-to-mask device
3. The next nursing action would be to start chest compression. Chest compressions are used to keep blood moving through the body and to the vital areas, such as the brain. After 2 minutes of compressions the rescuer opens the victim's airway.
The nurse attempts to relieve an airway obstruction in a 3-year-old conscious child. The nurse performs the abdominal thrust maneuver correctly by standing behind the child, placing her arms under the child's axillae and around the child, and positioning her hands to deliver the thrusts between which areas? 1. Groin and the abdomen 2. Umbilicus and the groin 3. Lower abdomen and the chest 4. Umbilicus and the xiphoid process
4. To perform abdominal thrusts on a child, the rescuer stands behind the victim and places the arms directly under the victim's axillae and around the victim. The rescuer places the thumb side of one fist against the victim's abdomen in the midline, slightly above the umbilicus and well below the tip of the xiphoid process. The rescuer grasps the fist with the other hand and delivers up to five thrusts. One must take care not to touch the xiphoid process or the lower margins of the rib cage because force applied to these structures may damage internal organs.
A client with severe hypothermia was found unresponsive. The cardiac monitor shows pulseless electrical activity (PEA) after 15 minutes of performing cardiopulmonary resuscitation (CPR). Which should be the nurse's next action? 1. Note the time of death. 2. Discuss options for care with the family. 3. Find out if the client has a living will. 4. Continue CPR.
4. Continue CPR.
An infant is to be discharged after surgery for intussusception. In developing the discharge teaching plan, the nurse should tell the mother: 1.The infant will experience a change in the normal home routine. 2.The infant can return to the prehospital routine immediately. 3.The infant needs to ingest more calories at home than what was consumed in the hospital. 4.The infant will continue to experience abdominal cramping for a few days.
1 Infants who have had an interruption in their normal routine and experiences, such as hospitalization and surgery, typically manifest behavior changes when discharged. The infant's normal routine has been significantly altered, so it will take time to reestablish another routine. Calorie requirements at home will continue to be the same as those in the hospital. The infant does not need more calories at home. The surgical procedure corrected the problems, so the infant should not continue to have abdominal cramping.
The nurse is performing rescue breathing on a 7-year-old infant. The nurse delivers one breath per how many seconds to the child? 1. 2-3 2. 6-8 3. 10-12 4. 12-14
1. In a infant between the ages of 1 and 8 years, one breath every 2-3 seconds is delivered.
The nurse is teaching cardiopulmonary resuscitation (CPR) to a group of nursing students. The nurse asks a student to describe the reason why blind finger sweeps are avoided in infants. The nurse determines that the student understands this reason if the student makes which statement? 1. "The object may have been swallowed." 2. "The infant may bite down on the finger." 3. "The mouth is too small eo see the object." 4. "The object may be forced back farther into the throat."
4. Blind finger sweeps are nit recommended for infants and children because of the risk of forcing the object farther down into the airway. The other options do not identify reasons for avoiding blind finger sweeps.
A mother and 7 month old infant present to the pediatric clinic. The infant appears developmentally appropriate and healthy, but the mother tells you that she is exacerbated. She says yesterday her infant had been incessantly crying with vomiting and jelly-like stool. But now, the infant appears fine. Which of the following GI disorders does the nurse suspect? A) Hypertrophic pyloric stenosis B) Celiac's disease C) Intussusception D) Encopresis
Answer: C. Intussusception is when a proximal portion of the bowel "telescopes" into a more distal portion. This produces sudden onset, crampy abdominal pain accompanied by currant jelly stools, vomiting, crying/knee drawing up, and lethargy. This disorder is episodic and often the bowel will suddenly reduce down temporarily eliminating symptoms.
The nurse is performing an admission assessment on an adult client with hypothermia. Which data should the nurse anticipate collecting during the health history portion of the nursing assessment? Select all that apply. A.Delayed capillary refill B.History of financial difficulties C.Drug or alcohol use D.Blood pressure E.History of exposure to environmental elements
B, C, E Rationale: During the health history portion of the nursing assessment, the nurse will assess the client's history of exposure to environmental elements and any financial difficulties that may prevent the client from adequately heating his home. The nurse would also anticipate a drug and alcohol history, which can place the client at a greater risk for hypothermia. The client's blood pressure and capillary refill are assessed during the physical exam portion of the nursing assessment.
What should be the nurses first action with a child who has a high fever dysphasia drooling tachycardia and tachypnea a. Immediate IV placement b. Immediate respiratory treatment c. Thorough physical assessment d. Lateral neck radiographs
D Lateral neck radiographs. D. This child is exhibiting signs and symptoms of epiglottitis and should be kept as comfortable as possible. The child should be allowed to remain in the parent's lap until a lateral neck film is obtained for a definitive diagnosis.
The nurse admitting a patient to the emergency room on a cold winter night would suspect hypothermia when the patient demonstrates A. Increased respirations. B. Rapid pulse rate. C. Red, sweaty skin. D. Slow capillary refill.
D. Slow capillary refill. With hypothermia, there is slow capillary refill. There is an increased respiration rate with hyperthermia. The heart rate increases with hyperthermia. The skin is usually pale or cyanotic with hypothermia.
Which client is at the greatest risk for hypothermia? 1. An 89-year-old client on a fixed income during cold winter months 2. A pregnant woman in her first trimester 3. A worker who repairs industrial freezers 4. A 3-hour-old infant swaddled in a blanket, wearing a hat, and being held by the mother
1. An 89-year-old client on a fixed income during cold winter months
A patient with hypothermia is brought to the emergency department. The nurse should explain to the family members that treatment will include A. Core rewarming with warm fluids. B. Ambulation to increase metabolism. C. Frequent oral temperature assessment. D. Gastric tube feedings to increase fluids.
A. Core rewarming with warm fluids. Core rewarming with heated oxygen and administration of warmed oral or intravenous fluids is the preferred method of treatment. The patient would be too weak to ambulate. Oral temperatures are not the most accurate assessment of core temperature because of environmental influences. Warmed oral feedings are advised; gastric gavage is unnecessary.
When obtaining the nursing history from the mother of an infant with suspected intussusception, which of the following questions would be most helpful? 1."What do the stools look like?" 2."When was the last time your child urinated?" 3."Is your child eating normally?" 4."Has your child had any episodes of vomiting?
1 For the infant with intussusception, stools characteristically have the appearance of currant jelly because of the intestinal inflammation and hemorrhage resulting from intestinal obstruction. These stools occur later in the course of the disease process. Questions that focus on urination, vomiting, and food intake do not elicit information about the effects of intussusception
A nasogastric tube inserted during surgery to correct an infant's intussusception is no longer freely removing gastric secretions. Which of the following should the nurse do next? 1.Aspirate the tube with a syringe. 2.Irrigate the tube with distilled water. 3.Increase the level of suction. 4.Rotate the tube.
1 The first action is to check the placement of the tube to ensure that it is in the correct position. To check tube position, the nurse should aspirate the tube with a syringe. A return of gastric contents indicates that the end of the tube is in the stomach. Another method is to inject a small amount of air while auscultating with a stethoscope over the epigastric area. The tube is irrigated with normal saline, not distilled water, and only after the position of the tube is confirmed. The suction level should not be increased, because doing so could damage the mucosa. Rotating the tube could irritate or traumatize the nasal mucosa
The nurse is visiting an older adult client who lives at home alone. Which assessment should the nurse make to determine the risk of hypothermia? Select all that apply. 1. Diet 2. Physical activity 3. Financial concerns 4. Blood glucose 5. Medications used
1. Diet 2. Physical activity 3. Financial concerns 5. Medications used
Which of the following assessments should be the priority for an infant who has had surgery to correct an intussusception and is now at risk for development of a paralytic ileus postoperatively? 1.Measurement of urine specific gravity. 2.Auscultation of bowel sounds. 3.Inspection of the first stool passed. 4.Measurement of gastric output.
2 Development of a paralytic ileus postoperatively is a functional obstruction of the bowel. Bowel sounds initially may be hyperactive, but then they diminish and cease. Measurement of urine specific gravity provides information about fluid and electrolyte status. The first stool and the amount of gastric output provide information about the return of gastric function.
When assessing a 4-month-old infant diagnosed with possible intussusception, the nurse should expect the mother to relate which of the following about the infant's crying and episodes of pain? 1.Constant accompanied by leg extension. 2.Intermittent with knees drawn to the chest. 3.Shrill during ingestion of solids. 4.Intermittent while being held in the mother's arms.
2 The infant with intussusception experiences acute episodes of colic-like abdominal pain. Typically, the infant screams and draws the knees to the chest. Between these episodes of acute abdominal pain, the infant appears comfortable and normal. Feeding does not precipitate episodes of pain. Additionally, a 4-month-old infant typically would not be ingesting solid foods. Pain exhibited by crying that occurs when the infant is placed in a reclining position, as in the mother's arms, is not associated with intussusception. This type of cry may indicate that the infant wants attention, wants to be held, or needs to have a diaper change
The nurse is caring for a 5-month-old infant with a diagnosis of intussusception. The infant has periods of irritability during which the knees are brought to the chest and the infant cries, alternating with periods of lethargy. Vital signs are stable and within age-appropriate limits. The health-care provider elects to give an enema. The parents ask the purpose of the enema. Which is the nurse's most appropriate response? 1. "The enema will confirm the diagnosis. If the test result is positive, your child will need to have surgery to correct the intussusception." 2. "The enema will confirm the diagnosis. Although very unlikely, the enema may also help fix the intussusception so that your child will not immediately need surgery." 3. "The enema will help confirm the diagnosis and has a good chance of fixing the intussusception." 4. "The enema will help confirm the diagnosis and may temporarily fix the intussusception. If the bowel returns to normal, there is a strong likelihood that the intussusception will recur."
3 1. The enema is used for confirmation of diagnosis and reduction. In most cases of intussusception in young children, an enema is successful in reducing the intussusception. 2. In most cases of intussusception in young children, an enema is successful in reducing the intussusception. 3. In most cases of intussusception in young children, an enema is successful in reducing the intussusception. 4. There is not a high likelihood that the intussusception will recur. TEST-TAKING HINT: The test taker needs to be aware that intussusceptions in young children respond well to reduction by enema.
The nurse is performing cardiopulmonary resuscitation (CPR) on an infant. When performing chest compressions the nurse compressses at least how many times? 1. 60 times per minute 2. 80 times per minute 3. 100 times per minute 4. 160 times per minute
3. In an infant, the rate of chest compressions is at least 100 times per minute.
A mother is crying and tells the nurse that she should have brought her son in yesterday when he said his throat was sore. Which is the nurse's best response to this parent whose child is diagnosed with epiglottitis and is in severe distress and in need of intubation? 1. "Children this age rarely get epiglottitis; you should not blame yourself." 2. "It is always better to have your child evaluated at the first sign of illness rather than wait until symptoms worsen." 3. "Epiglottitis is slowly progressive, so early intervention may have decreased the extent of your son's symptoms." 4. "Epiglottitis is rapidly progressive; you could not have predicted his symptoms would worsen so quickly."
4 1. Epiglottitis is most common in children from 2 to 5 years of age. The onset is very rapid. Telling parents not to blame themselves is not effective. Parents tend to blame themselves for their child's illnesses even though they are not responsible. 2. The nurse should not tell the parent to seek medical attention for any and all signs of illness. 3. Epiglottitis is rapidly progressive and cannot be predicted. 4. Epiglottitis is rapidly progressive and cannot be predicted. TEST-TAKING HINT: When something happens to a child, the parents always blame themselves. Telling them epiglottitis is rapidly progressive may be helpful.
The nurse will soon receive a 4-month-old who has been diagnosed with intussusception. The infant is described as very lethargic with the following vital signs: T 101.8°F (38.7°C), HR 181, BP 68/38. The reporting nurse states the infant ' s abdomen is very rigid. Which is the most appropriate action for the receiving nurse? 1. Prepare to accompany the infant to a computed tomography scan to confirm the diagnosis. 2. Prepare to accompany the infant to the radiology department for a reducing enema. 3. Prepare to start a second intravenous line to administer fluids and antibiotics. 4. Prepare to get the infant ready for immediate surgical correction.
4 1. The child has already been diagnosed and appears to have developed peritonitis, which is a surgical emergency. 2. Although reducing enemas have a high success rate among infants with intussusception, they are contraindicated in the presence of peritonitis. 3. Although a second intravenous line may be needed, the nurses first priority is getting the child to the operating room. 4. Intussusception with peritonitis is a surgical emergency, so preparing the infant for surgery is the nurse ' s top priority. TEST-TAKING HINT: The child has already been diagnosed and is displaying signs of shock and peritonitis. The nurse must act quickly and get the child the surgical attention needed to avoid disastrous consequences.
The nurse is caring for a client diagnosed with hypothermia. Which observation indicates to the nurse that the treatment is effective? 1. The client's core temperature is 33.7 degrees°C (92.6 degrees°F). 2. The client begins shivering. 3. The client is unable to generate her own heat. 4. The client reports thermal comfort.
4. The client reports thermal comfort. Thermal comfort indicates normal thermoregulation. Shivering, decreased core body temperature, and inability to generate heat are all indications that the client is still in hypothermia.
The nurse understands that which is a correct guideline for adult cardiopulmonary resuscitation (CPR) for a health care provider (HCP)? 1. One breath should be given for every five compressions 2. Two breaths should be given for every 15 compressions 3. Initially, two quick breaths should be given as rapidly as possible 4. Each rescue breath should be given over 1 second and should produce a visible chest rise
4. In adult CPR, each rescue breath should be given over 1 second and should produce a visible chest rise. Excessive ventilation (too many breaths per minute or breaths that are too large or forceful) may be harmful and should not be performed. HCP's should employ a 30:2 compression-to-ventilation ratio for the adult victim.
The nurse caring for a client with hypothermia understands the compensatory mechanisms that are activated during this condition to decrease oxygen demands on the body. Which clinical manifestation should the nurse expect upon assessment for this client? Select all that apply. 1.Increased respiratory rate 2.Increased GI motility 3.Increased heart rate 4.Decreased respiratory rate 5.Decreased heart rate
4.Decreased respiratory rate 5.Decreased heart rate
A homeless person is brought to the emergency department after prolonged exposure to cold weather. The nurse would assess the patient for manifestations of hypothermia, including A. Stupor. B. Erythema. C. Increased anxiety. D. Rapid respirations.
A. Stupor. Stupor may occur with hypothermia because of slowed cerebral metabolic processes. Pallor, not erythema, would be present as a result of peripheral vasoconstriction. Drowsiness occurs; the patient would be unable to focus on anxiety-producing aspects of the situation. Respirations would be decreased.
A mother and 7 month old infant present to the pediatric clinic. The infant appears developmentally appropriate and healthy, but the mother tells you that she is exacerbated. She says yesterday her infant had been incessantly crying with vomiting and jelly-like stool. But now is fine. What is the nurse's first action? A) Determine prenatal status of the mother and child B) Prepare the child for immediate surgery C) Palpate the stomach for a mass D) Administer barium enema
Answer: C. The nurse would further assess the child. The nurse suspects this child to possibly have intussusception. A "sausage-like" mass in the upper mid-abdomen is a hallmark sign of intussusception. It may not be present at this time, but it would be important to assess for this finding. A barium enema is often used to treat this disorder. Surgery can also be used. The prenatal status of the mother/child would not be a priority assessment.
Nurse is assessing a child recently brought to ED. based on the notes, which observations would cause the nurse to suspect epiglottitis. Select all that apply. A. Excessive crying B. Drooling C. Low grade fever D. Spontaneous cough E. Refusal to lie down
B, E Drooling of saliva is common due to the pain of swallowing excessive secretions, and a sore throat. The child will usually have a high fever, but no spontaneous cough. The child may place themselves in a tripod position with their mouth open and tongue protruding
Which is diagnostic for epiglottitis A. Blood test B. Throat swab C. Lateral neck x-ray of the soft tissue D. Signs and symptoms
C. Lateral neck x-ray of the soft tissue. A lateral neck x-ray is a definitive test to diagnose epiglottitis. The child is at risk for complete airway obstruction and should always be accompanied by a nurse to the x-ray department.
A priority nursing intervention for a patient with hyperthermia would be A. Initiating seizure precautions. B. Limiting oral intake. C. Providing a blanket. D. Removing excess clothing.
D. Removing excess clothing. Rationale The priority nursing intervention would be removal of excess clothing. Seizures may occur because of a high body temperature, but seizure precautions should not be the first intervention. Oral intake, especially of fluids, should not be limited for a patient with hyperthermia, because of the dangers of dehydration. Blanketing, like clothing, should be removed.
When caring for a toddler with epiglottitis, the nurse should first: a) examine his throat. b) administer I.V. fluids. c) administer antibiotics. d) place a tracheotomy tray at the bedside.
D. place a tracheotomy tray at the bedside. Placing a tracheotomy tray at the bedside should take priority because acute epiglottitis is an emergency situation in which inflammation can cause the epiglottis to swell, totally obstructing the airway. This situation may require tracheotomy or endotracheal intubation.
