Pediatric Respiratory Disorders
Pancreatic enzymes are administered to the child with cystic fibrosis. What information should be included in patient education concerning the administration of these enzymes? A.Do not administer pancreatic enzymes if the child is receiving antibiotics. B.Decrease dose of pancreatic enzymes if the child is having frequent, bulky stools. C.Administer pancreatic enzymes between meals if at all possible. D.Pancreatic enzymes can be swallowed whole or sprinkled on a small amount of food taken at the beginning of a meal.
ANS: D Enzymes may be administered in a small amount of cereal or fruit or swallowed whole at the beginning of a meal, not between meals. Pancreatic enzymes are not contraindicated with antibiotics. The dose of enzymes should be increased if the child is having frequent, bulky stools.
Which vitamin supplements are necessary for children with cystic fibrosis? Vitamin C and calcium Vitamins B6 and B12 Magnesium Vitamins A, D, E, and K
ANS: D Fat-soluble vitamins are poorly absorbed because of deficient pancreatic enzymes in children with cystic fibrosis; therefore, supplements are necessary. Vitamin C and calcium are not fat soluble. Vitamins B6 and B12 are not fat-soluble vitamins. Magnesium is a mineral, not a vitamin.
When should the parent of an infant with nasopharyngitis be instructed to notify the health care professional? A.Becomes fussy B.Has a cough C.Has a fever over 99° F D.Shows signs of an earache
ANS: D If an infant with nasopharyngitis has a fever over 101° F, there is early evidence of respiratory complications. Irritability and a slight fever are common in an infant with a viral illness. Cough can be a sign of nasopharyngitis
Which information should the nurse stress to workers at a day care center about respiratory syncytial virus (RSV)? RSV is transmitted through particles in the air. RSV can live on skin or paper for up to a few seconds after contact. RSV can survive on nonporous surfaces for about 60 minutes. Frequent hand washing can decrease the spread of the virus.
ANS: D Meticulous hand washing can decNreUaRseSItNhGeTsBpr.CeaOdMof organisms. RSV infection is not airborne. It is acquired mainly through contact with contaminated surfaces. RSV can live on skin or paper for up to 1 hour and on cribs and other nonporous surfaces for up to 6 hours.
Why do infants and young children quickly have respiratory distress in acute and chronic alterations of the respiratory system? They have a widened, shorter airway. There is a defect in their sucking ability. The gag reflex increases mucus production. Mucus and edema obstruct small airways.
ANS: D The airway in infants and young children is narrower, not wider, and respiratory distress can occur quickly because mucus and edema can cause obstruction to their small airways. Sucking is not necessarily related to problems with the airway. The gag reflex is necessary to prevent aspiration. It does not produce mucus.
In providing nourishment for a child with cystic fibrosis (CF), what diet consideration should be stressed to both the child and caregivers? A.Diet should be high in carbohydrates and protein. B.Diet should be high in easily digested carbohydrates and fats. C.Most fruits and vegetables are not well tolerated. d. Fats and proteins must be greatly curtailed.
ANS: A Children with CF require a well-balanced, high-protein, high-calorie diet because of impaired intestinal absorption. Enzyme supplementation helps digest foods; other modifications are not necessary. A well-balanced diet containing fruits and vegetables is important. Fats and proteins are a necessary part of a well-balanced diet.
A child has a chronic, nonproductive cough and diffuse wheezing during the expiratory phase of respiration. This suggests which respiratory condition? A.Asthma B.Pneumonia C.Bronchiolitis D.Foreign body in the trachea
ANS: A Children with asthma usually have these chronic symptoms. Pneumonia appears with an acute onset and fever and general malaise. Bronchiolitis is an acute condition caused by respiratory syncytial virus. Foreign body in the trachea will manifest with acute respiratory distress or failure and maybe stridor.
A nurse is charting that a hospitalized child has labored breathing. Which medical term describes labored breathing? a. Dyspnea b. Tachypnea c. Hypopnea d. Orthopnea
ANS: A Dyspnea is labored breathing. Tachypnea is rapid breathing. Hypopnea is breathing that is too shallow. Orthopnea is difficulty breathing except in upright position.
What are the earliest recognizable clinical manifestations of cystic fibrosis (CF)? A.Meconium ileus B.History of poor intestinal absorption C.Foul-smelling, frothy, greasy stools D.Recurrent pneumonia and lung infections
ANS: A The earliest clinical manifestation of CF is a meconium ileus, which is found in about 10% of children with CF. Clinical manifestations include abdominal distention, vomiting, failure to pass stools, and rapid development of dehydration. History of malabsorption is a later sign that manifests as failure to thrive. Foul-smelling stools and recurrent respiratory infections are later manifestations of CF.
Instructions for decongestant nose drops should include what recommendation? A.Avoiding use for more than 3 days. B.Keeping drops to use again for nasal congestion. C.Administering drops until nasal congestion subsides. D.Administering drops after feedings and at bedtime.
ANS: A Vasoconstrictive nose drops should not be used for more than 3 days to avoid rebound congestion. Drops should be discarded after one illness because they may become contaminated with bacteria. Vasoconstrictive nose drops can have a rebound effect after 3 days of use. Drops administered before feedings are more helpful.
The nurse is assessing a child with acute epiglottitis. Examining the child's throat by using a tongue depressor might precipitate which symptom or condition? Inspiratory stridor Complete obstruction Sore throat Respiratory tract infection
ANS: B If a child has acute epiglottitis, examination of the throat may cause complete obstruction and should be performed only when immediate intubation can take place. Stridor is aggravated when a child with epiglottitis is supine. Sore throat and pain on swallowing are early signs of epiglottitis. Epiglottitis is caused by Haemophilus influenzae in the respiratory tract.
The nurse is caring for a child diagnosed with acute respiratory distress syndrome (ARDS) associated with sepsis. What nursing intervention should be included in the plan of care? A.Force fluids B.Monitor pulse oximetry C.Institute seizure precautions D.Encourage a high-protein diet
ANS: B Monitoring cardiopulmonary status is an important evaluation tool in the care of the child with ARDS. Maintenance of vascular volume and hydration is important and should be done parenterally. Seizures are not a side effect of ARDS. Adequate nutrition is necessary, but a high-protein diet is not helpful.
-Adrenergic agonists and methylxanthines are often prescribed for a child with an asthma attack for what resulting action? A.Liquefaction of secretions B.Dilation of the bronchioles C.Reduction of inflammation of the lungs D.Reduction of existing infection
ANS: B These medications work to dilate the bronchioles in acute exacerbations. These medications do not liquefy secretions or reduce infection. Corticosteroids and mast cell stabilizers reduce inflammation in the lungs.
A child diagnosed with cystic fibrosis is prescribed recombinant human deoxyribonuclease (rhDNase). What information should be included in the medication education provided the child and family? A.May cause mucus to thicken B.May cause minor voice alterations C.Is given subcutaneously D.Is not indicated for children younger than 12 years
ANS: B Two of the only adverse effects of rhDNase are voice alterations and laryngitis. rhDNase decreases viscosity of mucus, is given in an aerosolized form, and is safe for children younger than 12 years of age.
Which intervention for treating croup at home should be taught to parents? Have a decongestant available to give the child when an attack occurs. Have the child sleep in a dry room. Take the child outside if air is cool and moist. Give the child an antibiotic at bedtime.
ANS: C Taking the child into the cool, humid, night air may relieve mucosal swelling and improve symptoms. Decongestants are inappropriate for croup, which affects the middle airway level. A dry environment may contribute to symptoms. Croup is caused by a virus. Antibiotic treatment is not indicated.
The nurse is caring for a 10-month-old infant diagnosed with respiratory syncytial virus (RSV) bronchiolitis. Which interventions should be included in the child's care? (Select all that apply.) Administer antibiotics Administer cough syrup Encourage infant to drink 8 ounces of formula every 4 hours Institute cluster care to encourage adequate rest Place on noninvasive oxygen monitoring
ANS: C, D, E Hydration is important in children with RSV bronchiolitis to loosen secretions and prevent shock. Clustering of care promotes periods of rest. The use of noninvasive oxygen monitoring is recommended.
A child with cystic fibrosis (CF) receives aerosolized bronchodilator medication. When should this medication be administered? Before chest physiotherapy (CPT) After CPT Before receiving 100% oxygen After receiving 100% oxygen
ANS: A Bronchodilators should be given before CPT to open bronchi and make expectoration easier. Aerosolized bronchodilator medications are not helpful when used after CPT. Oxygen administration is necessary only in acute episodes with caution because of chronic carbon dioxide retention.
The nurse encourages the mother of a toddler with acute laryngotracheobronchitis (LTB) to stay at the bedside as much as possible. What is the nurse's primary rationale for this action? A.Mothers of hospitalized toddlers often experience guilt. B.The mother's presence will reduce anxiety and ease the child's respiratory efforts. C.Separation from the mother is a major developmental threat at this age. D.The mother can provide constant observations of the child's respiratory efforts.
ANS: B The family's presence will decrease the child's distress. The mother may experience guilt, but this is not the best answer. Although separation from the mother is a developmental threat for toddlers, the main reason to keep parents at the child's bedside is to ease anxiety and therefore respiratory effort. The child should have constant cardiorespiratory monitoring and noninvasive oxygen saturation monitoring, but the parent should not play this role in the hospital.
A school-age child has had an upper respiratory tract infection for several days and then began having a persistent dry, hacking cough that was worse at night. The cough has become productive in the past 24 hours. This assessment is most suggestive of what respiratory airway disorder? A.Bronchitis B.Bronchiolitis C.Viral-induced asthma D.Acute spasmodic laryngitis
ANS: A Bronchitis is characterized by these symptoms and occurs in children older than 6 years. Bronchiolitis is rare in children older than 2 years. Asthma is a chronic inflammation of the airways that may be exacerbated by a virus. Acute spasmodic laryngitis occurs in children between 3 months and 3 years.
Which statement expresses accurately the genetic implications of cystic fibrosis (CF)? A.If it is present in a child, both parents are carriers of this defective gene. B.It is inherited as an autosomal dominant trait. C.It is a genetic defect found primarily in non-Caucasian population groups. D.There is a 50% chance that siblings of an affected child also will be affected.
ANS: A CF is an autosomal recessive geneNiUnRhSeIrNitGedTBfr.ComOMboth parents and is found primarily in Caucasian populations. An autosomal recessive inheritance pattern means that there is a 25% chance that a sibling will be infected but a 50% chance a sibling will be a carrier.
An infant's parents ask the nurse about preventing otitis media (OM). What intervention should the nurse recommend? A.Avoid tobacco smoke B.Use nasal decongestant C.Avoid children with OM D.Bottle-feed or breastfeed in supine position
ANS: A Eliminating tobacco smoke from the child's environment is essential for preventing OM and other common childhood illnesses. Nasal decongestants are not useful in preventing OM. Children with uncomplicated OM are not contagious unless they show other upper respiratory infection symptoms. Children should be fed in an upright position to prevent OM.
A nurse is conducting an in-service on asthma. Which statement is the most descriptive of bronchial asthma? There is heightened airway reactivity. There is decreased resistance in the airway. The single cause of asthma is an allergic hypersensitivity. It is inherited.
ANS: A In bronchial asthma, spasm of the smooth muscle of the bronchi and bronchioles causes constriction, producing impaired respiratory function. In bronchial asthma, there is increased resistance in the airway. There are multiple causes of asthma, including allergens, irritants, exercise, cold air, infections, medications, medical conditions, and endocrine factors. Atopy or development of an immunoglobulin E (IgE)-mediated response is inherited but is not the only cause of asthma.
What nursing intervention should be included in the plan of care for a young child diagnosed with pneumonia? Monitor for abdominal pain Encourage the child to lie on the unaffected side c. Administer analgesics d. Place the child in the Trendelenburg position
ANS: A The pain of pneumonia may be referred to the abdomen in young children. Lying on the affected side may promote comfort by splinting the chest and reducing pleural rubbing. Analgesics are not indicated. Children should be placed in a semierect position or position of comfort.
Which information should the nurse teach families about reducing exposure to pollens and dust? (Select all that apply.) Replace wall-to-wall carpeting with wood and tile floors Use an air conditioner Put dust-proof covers on pillows and mattresses Keep humidity in the house above 60% Keep pets outside
ANS: A, B, C Carpets retain dust. To reduce exposure to dust, carpeting should be replaced with wood, tile, slate, or vinyl. These floors can be cleaned easily. For anyone with pollen allergies, it is best to keep the windows closed and to run the air conditioner. Covering mattresses and pillows with dust-proof covers will reduce exposure to dust. A humidity level above 60% promotes dust mites. It is recommended that household humidity be kept between 40% and 50% to reduce dust mites inside the house. Keeping pets outside will help to decrease exposure to dander, but will not affect exposure to pollen and dust.
The nurse is caring for a child with carbon monoxide (CO) poisoning associated with smoke inhalation. What intervention is essential in this child's care? A.Monitor pulse oximetry B.Monitor arterial blood gases (ABGs) C.Administer oxygen if respiratory distress develops D.Administer oxygen if child's lips become bright, cherry red
ANS: B Arterial blood gases (ABGs) and COHb levels are the best way to monitor CO poisoning. PaO2 monitored with pulse oximetry may be normal in the case of CO poisoning. Oxygen at 100% should be given as quickly as possible, not only if respiratory distress or other symptoms develop.
Which statement best describes why children have fewer respiratory tract infections as they grow older? A.The amount of lymphoid tissue decreases. B.Repeated exposure to organisms causes increased immunity. C.Viral organisms are less prevalent in the population. D.Secondary infections rarely occur after viral illnesses.
ANS: B Children have increased immunity after exposure to a virus. The amount of lymphoid tissue increases as children grow older. Viral organisms are not less prevalent, but older children have the ability to resist invading organisms. Secondary infections after viral illnesses include Mycoplasma pneumoniae and groups A and B streptococcal infections.
Which type of croup is always considered a medical emergency? A.Laryngitis B.Epiglottitis C.Spasmodic croup D.Laryngotracheobronchitis (LTB)
ANS: B Epiglottitis is always a medical emergency needing antibiotics and airway support for treatment. Laryngitis is a common viral illness in older children and adolescents with hoarseness and upper respiratory infection symptoms. Spasmodic croup is treated with humidity. LTB may progress to a medical emergency in some children.
What distinguishing manifestation of spasmodic croup should parents be taught to identify? Wheezing is heard audibly It has a harsh, barky cough It is bacterial in nature The child has a high fever
ANS: B Spasmodic croup is viral in origin, is usually preceded by several days of symptoms of upper respiratory tract infection, and often begins at night. It is marked by a harsh, metallic, barky cough; sore throat; inspiratory stridor; and hoarseness. Wheezing is not a distinguishing manifestation of croup. It can accompany conditions such as asthma or bronchiolitis. A high fever is not usually present.
When it is generally recommended that a child being treated for acute streptococcal pharyngitis may return to school? A.When the sore throat is better B.If no complications develop C.After taking antibiotics for 24 hours D.After taking antibiotics for 3 days
ANS: C After children have taken antibiotics for 24 hours, even if the sore throat persists, they are no longer contagious to other children. Complications may take days to weeks to develop.
An 8-year-old child is diagnosed with influenza, probably type A disease. What intervention should be included in the plan of care? A.Clear liquid diet for hydration B.Aspirin to control fever C.Oseltamivir to reduce symptoms D.Antibiotics to prevent bacterial infection
ANS: C Oseltamivir may reduce symptoms related to influenza type A if administered within 48 hours of onset of symptoms. It is effective against type A or B. A clear liquid diet is not necessary for influenza, but maintaining hydration is important. Aspirin is not recommended in children because of increased risk of Reye's syndrome. Acetaminophen or ibuprofen is a better choice. Preventive antibiotics are not indicated for influenza unless there is evidence of a secondary bacterial infection.
A parent whose two school-age children diagnosed with exercise-induced bronchospasm (EIB) asks the nurse in what sports, if any, they can participate. The nurse should recommend which sport? a. Soccer b. Running c. Swimming d. Basketball
ANS: C Swimming is well tolerated in children with EIB because they are breathing air fully saturated with moisture and because of the type of breathing required in swimming. Exercise-induced bronchospasm is more common in sports that involve endurance, such as soccer, running, and basketball. Prophylaxis with medications may be necessary.
It is now recommended that children with asthma who are taking long-term inhaled steroids should be assessed frequently to monitor for what increased risk? A.Cough B.Osteoporosis C.Slowed growth D.Cushing's syndrome
ANS: C The growth of children on long-term inhaled steroids should be assessed frequently to assess for systemic effects of these drugs. Cough is prevented by inhaled steroids. No evidence exists that inhaled steroids cause osteoporosis. Cushing's syndrome is caused by long-term systemic steroids.
Cystic fibrosis (CF) is suspected in a toddler. Which test is essential in establishing this diagnosis? A.Bronchoscopy B.Serum calcium C.Urine creatinine D.Sweat chloride test
ANS: D A sweat chloride test result greater than 60 mEq/L is diagnostic of CF. Although bronchoscopy is helpful for identifying bacterial infection in children with CF, it is not diagnostic. Serum calcium is normal in children with CF. Urine creatinine is not diagnostic of CF.
A nurse providing care to a child diagnosed with chronic otitis media with effusion (OME) will assess for which sign/symptom? A.Fever as high as 40° C (104° F) B.Severe pain in the ear c. Nausea and vomiting d. A feeling of fullness in the ear
ANS: D OME is characterized by an immobile or orange-discolored tympanic membrane and nonspecific complaints of fullness in the ear. OME does not generally cause severe pain. Fever and severe pain may be signs of AOM. Nausea and vomiting are associated with otitis media.
A nurse in an emergency department is caring for a toddler who is in acute respiratory distress. Which of the following findings should alert the nurse to the possibility of epiglottitis? A. Lethargy )B. Spontaneous coughing C. Drooling D. Hoarseness
Correct Answer: C. Drooling Epiglottitis is a disorder caused by an inflammation of the epiglottis. It results in rapid swelling of the epiglottis, which can obstruct breathing. Drooling is an expected finding due to the toddler's inability to swallow saliva. Incorrect Answers: A. A toddler who has epiglottitis is restless and appears anxious rather than lethargic B. A toddler who has epiglottitis has an absence of spontaneous coughing due to inflammation of the epiglottis. D. Hoarseness would be present in a toddler who has acute spasmodic laryngitis rather than epiglottitis.
Parents have understood teaching about prevention of childhood otitis media if they make which statement? "We will only prop the bottle during the daytime feedings." "Breastfeeding will be discontinued after 4 months of age." "We will place the child flat right after feedings." "We will be sure to keep immunizations up to date."
ANS: D Parents have understood the teaching about preventing childhood otitis media if they respond they will keep childhood immunizations up to date. The child should be maintained upright during feedings and after. Otitis media can be prevented by exclusively breastfeeding until at least 6 months of age. Propping bottles is discouraged to avoid pooling of milk while the child is in the supine position.
When caring for an infant with an upper respiratory tract infection and elevated temperature, which appropriate nursing intervention should the nurse implement? A.Give tepid water baths to reduce fever. B.Encourage food intake to maintain caloric needs. C.Have child wear heavy clothing to prevent chilling. D.Give small amounts of favorite fluids frequently to prevent dehydration.
ANS: D Preventing dehydration by small frequent feedings is an important intervention in the febrile child. Tepid water baths may induce shivering, which raises temperature. Food should not be forced; it may result in the child vomiting. The febrile child should be dressed in light, loose clothing.
A nurse is providing dietary teaching to the parent of a toddler who has cystic fibrosis. Which of the following instructions should the nurse include? A. Provide a high-fat diet for the toddler B. Limit the toddler's daily intake of sodium C. Increase the toddler's intake of foods high in folic acid D. Allow the toddler to skip meals when he is not hungry
Correct Answer: A. Provide a high-fat diet for the toddler Children who have cystic fibrosis have impaired intestinal absorption of fat. Therefore, the toddler will require an increased intake of fat. Incorrect Answers: B. The parent does not need to restrict the toddler's intake of sodium. C. The parent should increase the toddler's dyily caloric intake. An increase in foods high in folic acid is not required for children who have cystic fibrosis. D. The parent should increase the toddler's daily caloric intake by 110% to 200% to meet increased nutritional needs. Therefore, the toddler should not skip meals.
A nurse is assessing a preschooler who has influenza and reports the new onset of a sore throat and difficulty swallowing. Which of the following findings is the priority for the nurse to report to the provider? A. The child's temperature is 39°C (102°F) B. The child's skin is sallow C. The child is drooling D. The child's voice is hoarse
When using the urgent versus nonurgent approach to client care, the nurse should determine that the presence of drooling is the priority finding because it can indicate the child might have developed epiglottitis, a medical emergency. Left untreated, the child can develop a complete respiratory obstruction. Incorrect Answers: A. A finding of sallow skin is an expected finding for a child who is ill. Therefore, there is another finding that is the nurse's priority. B. An elevated temperature is an expected finding for a child who has influenza Therefore, there is another finding that is the nurse's priority. D. A report of a hoarse voice is an expected finding for a child who has a sore throat. Therefore, there is another finding that is the nurse's priority.
Abdominal thrusts are recommended for airway obstruction in children older than: 1 year. 4 years. 8 years. 12 years.
ANS: A Abdominal thrusts are recommended for airway obstruction in children older than 1 year. In children younger than 1 year, back blows and chest thrusts are administered.
An 18-month-old child is seen in the clinic is diagnosed with acute otitis media (AOM). Oral amoxicillin is prescribed. Which statement made by the parent indicates a correct understanding of the instructions? "I should administer all the prescribed medication." "I should continue medication until the symptoms subside." "I will immediately stop giving medication if I notice a change in hearing." "I will stop giving medication if fever is still present in 24 hours."
ANS: A Antibiotics should be given for their full course to prevent recurrence of infection with resistant bacteria. Symptoms may subside before the full course is given. Hearing loss is a complication of AOM. Antibiotics should continue to be given. Medication may take 24 to 48 hours to make symptoms subside. It should be continued.
A nurse is providing teaching about disease-management strategies to a 9-year-old client who has cystic fibrosis. Which of the following statements should the nurse include? A. "Thorough and effective pulmonary clearance can help prevent the need for a lung transplant when you get older." B. "You should eat these kinds of foods because they will help you grow big and strong. C. "Your mucus is thick because cystic fibrosis interferes with how your glands work." D. "Your medication follows a certain schedule to help you sleep better."
Answer: C. A 9-year-old child should understand that the production of thick mucus is a part of the disease process. Incorrect Answers: A. School-age children do not engage in abstract thought and reasoning because they are unable to grasp the reality of long-term consequences. This statement would be appropriate for an adolescent client. B. School-age children want toyinderstand how things work. Any explanation should include appropriate scientific and medical terminology. D. This statement does not explain the pathophysiology of cystic fibrosis, why it interferes with sleep, or how the medicine will help.
A nurse is providing teaching to the parent of a child who has cystic fibrosis and a prolapsed rectum. The nurse should identify that which of the following is a cause of this complication? A. Bulky stools B. Weakened rectal sphincter C. Elevated pancreatic enzymes D. Decreased intra-abdominal pressure
Correct Answer: A. Bulky stools The nurse should identify that bulky stools can cause a child who has cystic fibrosis to develop a prolapsed rectum. The nurse should implement interventions to help decrease the bulk of the child's stools. Incorrect Answers: B. The nurse should identify that a weakened rectal sphincter is not a manifestation of cystic fibrosis. C. The nurse should identify that a prolapsed rectum is associated with insufficient pancreatic enzymes. D. The nurse should identify that a prolapsed rectum is associated with increased intra- abdominal pressure
A nurse is providing dietary teaching to the parent of a child who has cystic fibrosis. Which of the following dietary recommendations should the nurse make? A. Increase the child's protein intake B. Decrease the child's calorie intake C. Increase the child's fiber intake D. Decrease the child's salt intake
Correct Answer: A. Increase the child's protein intake The nurse should recommend an increased protein intake for the child who has cystic fibrosis. These children require up to 150% of the recommended daily allowance to meet their nutritional needs. Incorrect Answers: B. The calorie intake for a child who has cystic fibrosis should be increased, not decreased. C. Increasing the child's fiber intake could increase bulk, and malabsorption might occur; therefore, it is not indicated for this child. D. Decreasing the child's salt intake is not indicated for cystic fibrosis.
A school nurse is assessing an adolescent who returned to school following a case of mononucleosis. The child has a note from his provider excusing him from gym class. Which of the following findings should the nurse identify as the reason for this excusal? A. Potential for sustaining abdominal trauma B. Deficient dietary intake c. Exposing peers to the illness D. Straining sore joints
Correct Answer: A. Potential for sustaining abdominal trauma An adolescent who has mononucleosis will have lymphadenopathy and often splenomegaly, which can persist for many months. For this reason, even after the adolescent is able to maintain his usual energy level and return to school, it is important for him to avoid activities that might result in trauma to the enlarged spleen. Incorrect Amswers: B. Although an adolescent who has mononucleosis might have difficulty swallowing in the early phases of the illness, after returning to school, he should not have deficient dietary intake. C. Epstein-Barr virus causes mononucleosis and is spread primarily through direct contact with the saliva of an infected individual. Casual contact during gym and recess would be no more hazardous than having the child in a classroom. D. An adolescent who has mononucleosis will not have joint inflammation.
A nurse is caring for a child who has an exacerbation of cystic fibrosis. Which of the following laboratory findings should the nurse report to the provider immediately? A. Blood glucose 140 mg/dL B. Oxygen saturation 85% C. RBC 3.2 million/uL D. Serum sodium 156 mEg/L
Correct Answer: B. Oxygen saturation 85% The nurse should apply the ABC priority-setting framework, which emphasizes the basic core of human functioning: having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these areas can indicate a threat to life and is the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear for oxygen exchange to occur. Breathing is the second-highest priority because adequate ventilatory effort is essential in order for oxygen exchange to occur circulation is the third-highest priority because the delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. Therefore, the nurse should report this finding to the provider immediately.
A nurse in an emergency department is assessing a school-aged child who is experiencing an acute asthma exacerbation. Which of the following findings is the priority for the nurse to report to the provider? A. Excessively prolonged expiration B. Increased diaphoresis C. Increased production of frothy sputum D. Sudden decrease in wheezing
Correct Answer: D. Sudden decrease in wheezing When applying the urgent versus nonurgent priority-setting framework, the nurse should consider urgent needs to be the priority because they pose a larger risk to the client. A sudden decrease in wheezing can indicate that the child is experiencing decreased air movement and should be reported to the provider. The nurse might also need to use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which finding is the most urgent. A sudden decrease in wheezing (silent chest) indicates ventilator failure and immiNOht respiratory arrest.
