A 3-year-old boy was successfully toilet trained prior to his admission to the hospital for injuries sustained from a fall. His parents are very concerned that the child has regressed in his toileting behaviors. Which information should the nurse provide to the parents?

Diapering will be provided since hospitalization is stressful to preschoolers.

A retraining program will need to be initiated when the child returns home.

A potty chair should be brought from home so he can maintain his toileting skills.

Children usually resume their toileting behaviors when they leave the hospital.

Answer and Explanation

The Correct Answer is D

The correct answer is choice d. Children usually resume their toileting behaviors when they leave the hospital.

Choice A rationale:

While it is true that hospitalization can be stressful for preschoolers, providing diapers may not be necessary. Regression in toileting is often temporary and related to the stress of the hospital environment.

Choice B rationale:

Initiating a retraining program immediately after returning home may not be necessary. Most children will naturally resume their previous toileting behaviors once they are back in a familiar and less stressful environment.

Choice C rationale:

Bringing a potty chair from home can be helpful in some cases, but it is not always practical or necessary. The child is likely to resume normal toileting behaviors once they are back in their usual environment.

Choice D rationale:

This is the correct answer because children often regress in their toileting behaviors due to the stress and unfamiliarity of the hospital environment. Once they return home, they typically resume their previous toileting habits.

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Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A,B"},"E":{"answers":"B"}}

Explanation

Course breath sounds - Respiratory Distress

Decreased level of consciousness - Cerebral Edema

Seizure activity - Cerebral Edema

Irritability - Both (Can be associated with both cerebral edema and respiratory distress)

Bradycardia - Cerebral Edema

Rationale:

Course breath sounds - Respiratory Distress

Course breath sounds could indicate the presence of secretions or fluid in the airways, which is a sign of respiratory distress. It suggests that there might be a problem with the airway or lung function.

Decreased level of consciousness - Cerebral Edema

A decreased level of consciousness can be a sign of cerebral edema, which is the swelling of the brain due to increased intracranial pressure. This can lead to changes in the child's mental status and responsiveness.

Seizure activity - Cerebral Edema

Seizure activity can be a manifestation of cerebral edema. Swelling and pressure in the brain can irritate brain tissue and lead to seizures.

Irritability - Both (Can be associated with both cerebral edema and respiratory distress) Irritability can be seen in both cerebral edema and respiratory distress. In cerebral edema, the pressure on the brain can cause discomfort and irritability. In respiratory distress, the child may be uncomfortable due to difficulty breathing.

Bradycardia - Cerebral Edema

Bradycardia (slow heart rate) can be associated with increased intracranial pressure and cerebral edema. It can be a response to the pressure on the brain.

A. Bilateral diffuse wheezing. B. Shortness of breath on exertion. C. Temperature of 100.5 °F (38.1 °C). D. Yellow expectorated sputum.

Correct Answer is B

Explanation

Shortness of breath on exertion in a client with a history of chronic obstructive pulmonary disease (COPD) and pneumonia indicates increased respiratory distress and compromised lung function. It suggests that the client is experiencing difficulty breathing even with minimal physical exertion. This finding may indicate worsening respiratory status, increased oxygen demand, and inadequate oxygenation. The nurse should take immediate action to address the shortness of breath, which may involve providing supplemental oxygen, initiating or adjusting bronchodilator medications, and monitoring the client's respiratory status closely. Prompt intervention is crucial to ensure adequate oxygenation and prevent respiratory failure.

While the other assessment findings (bilateral diffuse wheezing, temperature of 100.5 °F, and yellow expectorated sputum) are also important and require attention, the shortness of breath on exertion poses the greatest immediate risk and necessitates immediate intervention to address the client's respiratory distress.

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A 3-year-old boy was successfully toilet trained prior to his admission to the hospital for injuries sustained from a fall. His parents are very concerned that the child has regressed in his toileting behaviors. Which information should the nurse provide to the parents?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits Click to mark whether the following are signs and symptoms of cerebral edema, respiratory distress, or both.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A,B"},"E":{"answers":"B"}}

Explanation

A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with pneumonia. Vital signs include: heart rate 122 beats/minute, respiratory rate 28 breaths/minute, and blood pressure 170/90 mmHg. Which assessment finding warrants the most immediate intervention by the nurse?

Correct Answer is B

Explanation

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