A 1-year-old child with respiratory syncytial virus (RSV) has been admitted to the pediatric unit. The nurse observes that the child has a fever, rhinorrhea, frequent coughing, and sneezing.
Which additional finding should alert the nurse that the child is in acute respiratory distress?
Flaring of the nares.
Bilateral bronchial breath sounds.
Diaphragmatic respirations.
A resting respiratory rate of 35 breaths/min.
The Correct Answer is A
Flaring of the nares is a sign of increased respiratory effort, which is a manifestation of acute respiratory distress. This finding occurs when the child is attempting to draw in more air to meet the increased demand for oxygen.
Bilateral bronchial breath sounds can indicate consolidation or a bronchial obstruction, but they are not specific to acute respiratory distress.
Diaphragmatic respirations are a normal finding and may occur in response to respiratory distress, but they do not necessarily indicate acute respiratory distress.
A resting respiratory rate of 35 breaths/min is within the normal range for a 1-year-old child and does not necessarily indicate acute respiratory distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
If a child's systolic blood pressure is greater than the 90th percentile during a routine clinic visit, the nurse should take the blood pressure two more times during the visit and determine the average of the three readings. This will provide a more accurate assessment of the child's blood pressure. Referring the child to the healthcare provider and scheduling an evaluation of blood pressure in two weeks
A. may be necessary if the child's blood pressure remains elevated, but it is not the next action that should be taken. Measuring the child's blood pressure three times during the visit and determining the highest of the readings
B. is not recommended because it may overestimate the child's blood pressure. Conducting a head-to-toe assessment and omitting repeated blood pressures during the examination
C. is not appropriate because it does not provide an accurate assessment of the child's blood pressure.
Correct Answer is ["B","D","F"]
Explanation
Answer: B, D, F
Rationale:
A) Understanding that nonstimulant medications show little benefit in treatment: This is inaccurate, as nonstimulant medications like atomoxetine can be effective for ADHD, especially in children who may not tolerate stimulants. Nonstimulants are often considered a viable alternative or adjunctive treatment.
B) Designating an established area for study: Creating a dedicated study space can help a child with ADHD focus on tasks and minimize distractions, which is beneficial for completing homework and improving concentration in a structured environment.
C) Anticipating being automatically entered into a specialized education plan: An Individualized Education Plan (IEP) or 504 Plan for ADHD is not automatic and typically requires evaluation and recommendation from school staff. The plan is individualized based on the child’s specific needs.
D) Knowing that medication is not always the best approach to treatment: Recognizing that treatment can involve behavioral interventions, counseling, and environmental adjustments, in addition to or instead of medication, reflects a balanced understanding of ADHD management.
F) Maintaining a consistent home schedule: Consistent routines help children with ADHD manage expectations and reduce stress, enhancing their ability to focus and transition smoothly between activities.
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