A 3-month-old with bronchiolitis is brought to the clinic experiencing irritability and poor oral intake. Which finding should alert the practical nurse (PN) that the child is in acute respiratory distress?
Flaring of the nares.
Resting respiratory rate of 35 breaths/minute.
Bilateral bronchial breath sounds.
Diaphragmatic respirations.
The Correct Answer is A
Flaring of the nares, or widening of the nostrils, is a sign of respiratory distress in infants. It indicates that the child is working harder to breathe. This finding should alert the practical nurse (PN) that the child with bronchiolitis is in acute respiratory distress.
A resting respiratory rate of 35 breaths/minute (B) is within the normal range for a 3-month-old infant. Bilateral bronchial breath sounds (C) and diaphragmatic respirations (D) are not specific signs of acute respiratory distress in infants.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The fact that the patient is being treated for depression and is currently taking an antidepressant medication suggests that his loss of interest in sexual intimacy may be related to his medication. Certain antidepressants can cause sexual dysfunction, including decreased libido.
Therefore, obtaining a list of medications currently being taken (A) is the most important information for the PN to obtain. While marital discord (B), frequency of sexual activity (C), and alcohol consumption (D) may be relevant information, they are not as directly related to the patient's current complaint as his medication use.
Correct Answer is D
Explanation
The pattern of bowel movements is the most important information for the practical nurse (PN) to obtain when assisting with the admission of a 12-month-old child with a history of frequent colds and growth failure who is being tested for a possible diagnosis of cystic fibrosis (CF). CF can cause thick, sticky mucus to build up in the digestive tract, leading to problems with digestion and absorption of nutrients. This can result in bulky, greasy stools and growth failure.
The number of respiratory infections since birth (Option A) and a description of the child's appetite (Option C) are also important pieces of information, but they are not as critical as the pattern of bowel movements. The number of siblings in the family ( Option B) is not directly relevant to the child's medical condition.
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