A 4-year-old girl is brought to the emergency department. She has a ‘frog-like’ croaking sound on inspiration, is agitated, and drooling. She insists on sitting upright. The nurse should do which of the following?
Make her lie down and rest quietly
Examine her oral pharynx and report to the physician
Auscultate her lungs and prepare for placement in a warm mist tent
Defer an oral assessment and be prepared to assist with a tracheostomy or intubation
The Correct Answer is D
a) Make her lie down and rest quietly: Inappropriate as the symptoms suggest potential airway obstruction.
b) Examine her oral pharynx and report to the physician: Important action, but immediate airway management is the priority.
c) Auscultate her lungs and prepare for placement in a warm mist tent: Less critical than ensuring an open airway.
d) Defer an oral assessment and be prepared to assist with a tracheostomy or intubation: The child's symptoms (stridor, agitation, drooling) indicate potential upper airway obstruction, and immediate readiness for airway intervention is essential.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
a) The infant having a higher basal metabolic rate: Basal metabolic rate doesn't directly impact urine specific gravity.
b) The infant’s kidneys being less able to concentrate urine: In fact, infants have immature kidneys that are less efficient at concentrating urine, but this is not the primary reason for lower specific gravity.
c) The infant having a greater percentage of body weight in water: Infants have a higher percentage of body weight in water, leading to more dilute urine.
d) The infant having a greater body surface area: While body surface area influences some aspects of renal function, it's not the main factor affecting urine specific gravity in infants.
Correct Answer is ["A","D","E"]
Explanation
a) Frequent blinking: Can indicate vision strain or discomfort.
b) Imitation of facial expressions: Typically, not directly related to vision impairment.
c) Appropriate eye contact: Good eye contact might be present despite vision impairment.
d) Tilting the head to the side when someone whispers: Could indicate an attempt to better hear or see, potentially indicating vision or hearing issues.
e) Rubbing eyes: Could suggest eye discomfort or vision problems.
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