A nurse in an urgent care clinic is prioritizing care for four children. Which of the following children should the nurse assess first?
A toddler who has nephrotic syndrome and facial edema.
An adolescent who has Crohn's disease and a recent weight loss of 5 kg (11 lb).
A preschool-age child who has a muffled voice and no spontaneous cough.
A school-age child who has diabetes mellitus and a blood glucose of 200 mg/dL.
The Correct Answer is C
A preschool-age child who has a muffled voice and no spontaneous cough should be assessed first.
These symptoms may indicate epiglottitis, which is a life-threatening condition that requires immediate medical attention.
Choice A, B and D are also important but not as urgent as choice C. A toddler with nephrotic syndrome and facial edema, an adolescent with Crohn’s disease and recent weight loss, and a school-age child with diabetes mellitus and a blood glucose of 200 mg/dL should be assessed after the preschool-age child with a muffled voice and no spontaneous cough.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is d. Exhibits head lag when pulled to a sitting position.
Choice A: Unable to hold a bottle At around 6 months of age, some babies can hold their own bottle. This is not a concerning finding for a 5-month-old infant. Therefore, this is not the correct answer.
Choice B: Unable to roll from back to abdomen Rolling over often starts around 4-6 months, so it’s not unusual for a 5-month-old to still be developing this skill. Therefore, this is not the correct answer.
Choice C: Absent grasp reflex The grasp reflex is an involuntary movement that your baby starts making in utero and continues doing until around 6 months of age. The grasp reflex lasts until the baby is about 5 to 6 months old. Therefore, this is not the correct answer.
Choice D: Exhibits head lag when pulled to a sitting position By the age of 5 months, most infants have developed enough strength in their neck and upper body to control their head movement. This means they should not exhibit a significant head lag when pulled to a sitting position1. If this is not the case, it could indicate a delay in motor development or a potential neurological issue, which should be reported to the healthcare provider for further evaluation. Therefore, this is the correct answer.
Correct Answer is ["A","B","D"]
Explanation
A. Offer the infant a pacifier during feedings.
B. Check for residual volumes by aspirating stomach contents.
D. Instill the formula over a period of 30 to 45 min.
Offering the infant a pacifier during feedings can help promote non-nutritive sucking and provide comfort to the infant.
Checking for residual volumes by aspirating stomach contents can help monitor gastric emptying and tolerance to enteral feeding.
Instilling the formula over a period of 30 to 45 min can help prevent overfeeding and reduce the risk of aspiration.
Choice C is wrong because placing the infant in a supine position during feedings increases the risk of aspiration.
The infant should be placed in an upright or semi-upright position during feedings.
Choice E is wrong because heating the formula to 39° C (102° F) prior to administration is not necessary and may even be harmful if the formula is overheated.
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