A 3-year-old admitted to the hospital with croup has the following vital signs: heart rate 90, respiratory rate 48, blood pressure 100/52, and temperature 98.8°F (37.1°C). The parents ask the nurse if these vital signs are normal. The nurse's best response is:
"Your son's respiratory rate is elevated, but the other vital signs are within the normal range."
"Your son's heart rate is elevated, but the other vital signs are within the normal range."
"Your son's blood pressure is elevated, but the other vital signs are within the normal range."
"Your son's temperature is elevated, but the other vital signs are within the normal range."
The Correct Answer is A
Choice A reason: This is the correct choice. A respiratory rate of 48 is high for a 3-year-old, indicating that the croup is affecting his breathing.
Choice B reason: This choice is incorrect. A heart rate of 90 is within the normal range for a 3-year-old.
Choice C reason: This choice is incorrect. A blood pressure of 100/52 is within the normal range for a 3-year-old.
Choice D reason: This choice is incorrect. A temperature of 98.8°F (37.1°C) is within the normal range for a 3-year-old.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
Choice A reason: This statement is not typically accurate; anti-seizure medications are not usually required for children who have had febrile seizures.
Choice B reason: There is no strong evidence that febrile seizures increase the risk for developmental delays.
Choice C reason: This is one of the correct choices. Antipyretics can help manage fever and may reduce the likelihood of a febrile seizure.
Choice D reason: This is one of the correct choices. Most children who experience febrile seizures do not have long-term effects or develop epilepsy.
Correct Answer is D
Explanation
Choice A reason: Movement of all extremities is expected and does not indicate a shunt malfunction.
Choice B reason: A negative Brudzinski sign is a normal finding and does not suggest a shunt malfunction.
Choice C reason: While incisional pain is common after surgery, it is not a specific indicator of shunt malfunction.
Choice D reason: This is the correct choice. A bulging fontanel can indicate increased intracranial pressure, which may suggest a shunt malfunction.
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