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) Poker chip tool: Typically used for older children who can understand and articulate pain levels.
b) Faces pain rating scale: Also used for older children who can express themselves using facial expressions.
c) FLACC pain scale: Designed for non-verbal or pre-verbal children, assessing facial expressions, leg movement, activity, cry, and consolability.
d) Duchar scale: There isn't a widely recognized pain assessment tool known as the "Duchar scale" in pediatric pain management
Correct Answer is D
Explanation
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.
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