A nurse in an emergency department is assessing a 3-year-old child who has a high fever, severe dyspnea, and is drooling. Which action is the nurse's priority?

Insert an IV catheter.

Prepare for nasotracheal intubation.

Administer an antipyretic.

Obtain blood culture specimens.

Answer and Explanation

The Correct Answer is B

Insert an IV catheter: While this might be necessary later, it’s not the immediate priority. The child’s breathing difficulty is the most urgent concern.
B. Prepare for nasotracheal intubation: This is the correct answer. The child’s severe dyspnea indicates a serious breathing problem. Nasotracheal intubation can help ensure the child’s airway remains open.
C. Administer an antipyretic: While this might help reduce the child’s fever, it won’t address the immediate life-threatening issue, which is the child’s difficulty breathing.
D. Obtain blood culture specimens: This could be helpful in diagnosing the cause of the child’s symptoms, but it’s not the immediate priority. The first concern should be stabilizing the child’s condition.

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Correct Answer is A

Explanation

A. “I am going to listen to your heart.”: This is the correct answer. It is a clear, simple statement that informs the child about what is going to happen. It is important to use language that is appropriate for the child’s age and development.
B. “Can I listen to your lungs?”: While this is a polite way to ask for consent, it might confuse a toddler who may not understand what “lungs” are.
C. “I am going to take your blood pressure now.”: This statement might be too complex for a toddler to understand. It’s better to use simpler language.
D. “Can you stand very still while I feel how warm you are?”: This statement might be confusing for a toddler. It’s better to use clear and direct language.

A. Muscular dystrophy B. Cerebral palsy C. Hydrocephalus D. Spina bifida

Correct Answer is D

Explanation

A. Muscular dystrophy: This is a group of diseases that cause progressive weakness and loss of muscle mass. It’s not a neural tube defect.
B. Cerebral palsy: This is a group of disorders that affect a person’s ability to move and maintain balance and posture. It’s not a neural tube defect.
C. Hydrocephalus: This is a condition that occurs when fluid builds up in the skull and causes the brain to swell. It’s not a neural tube defect, but it can occur as a complication of spina bifida.
D. Spina bifida: This is the correct answer. Spina bifida is a neural tube defect that occurs when the spine and spinal cord don’t form properly. This is a condition that is present at birth (congenital).

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A nurse in an emergency department is assessing a 3-year-old child who has a high fever, severe dyspnea, and is drooling. Which action is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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