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
Bradycardia, or a slow heart rate, is a sign of digoxin toxicity in infants.
Digoxin is a medication used to improve the strength and efficiency of the heart and to control the rate and rhythm of the heartbeat.
However, an overdose can cause changes in the rate or rhythm of the heartbeat, including bradycardia.
Choice A is wrong because polyuria is not a sign of digoxin toxicity.
Choice B is wrong because diaphoresis is not a sign of digoxin toxicity.
Choice D is wrong because jaundice is not a sign of digoxin toxicity.
Correct Answer is A
Explanation
An adolescent who has sickle cell anemia and slurred speech should be assessed first.
Slurred speech can be a sign of a stroke, which is a known complication of sickle cell anemia.
This requires immediate medical attention.
Choice B is wrong because while pain management is important, it is not as urgent as a potential stroke.
Choice C is wrong because while administering medication is important, it is not as urgent as a potential stroke.
Choice D is wrong because while wound care is important, it is not as urgent as a potential stroke.
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