A nurse in the emergency department is caring for a school-age child who has developed respiratory stridor, wheezing, and urticaria after receiving an IV medication. Which of the following actions should the nurse take first?
Administer methylprednisolone.
Administer oxygen.
Administer epinephrine.
Administer a nebulized bronchodilator.
The Correct Answer is C
A. Methylprednisolone is a corticosteroid that can help reduce inflammation. While it may be beneficial in some cases of allergic reactions, it is not the first-line treatment for severe
anaphylaxis. In this situation, the priority is to address the immediate symptoms and stabilize the child's condition.
B. Administering oxygen is an important intervention, especially if the child is experiencing respiratory distress. However, in the case of severe anaphylaxis, administering epinephrine is the highest priority as it addresses multiple aspects of the reaction, including airway constriction,
low blood pressure, and hives.
C. This is the correct action. Epinephrine is the first-line treatment for anaphylaxis. It works rapidly to improve breathing, increase blood pressure, and reduce allergic symptoms. It is considered the most critical intervention in this situation.
D. Nebulized bronchodilators can be beneficial for respiratory distress, but they are not the first-line treatment for severe anaphylaxis. Epinephrine is more effective in rapidly reversing the
allergic reaction and stabilizing the child's condition. It addresses a broader range of symptoms in anaphylaxis compared to a bronchodilator.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. This statement demonstrates an understanding of a helpful strategy for managing encopresis. Having the child try to defecate 15 minutes after each meal can take advantage of the body's natural reflexes and increase the likelihood of regular bowel movements.
B. Limiting fluid intake is not a recommended strategy for managing encopresis.
Maintaining proper hydration is important for overall health.
C. Having the child sit on the toilet for extended periods of time may lead to frustration and aversion to toilet training. It is not a recommended approach.
D. Increasing dairy intake is not a specific strategy for managing encopresis. In fact, some dairy products can contribute to constipation in some individuals. A balanced diet with an appropriate amount of fiber is important for bowel regularity.
Correct Answer is A
Explanation
A. A toddler's repeated refusal to let a nurse perform a routine medical assessment may indicate fear or discomfort around adults, which could be a potential indicator of child abuse or neglect.
B. A mother's hesitation to comfort her 6-month-old infant may be due to various reasons, such as cultural differences, lack of confidence, or personal preferences. It is not necessarily indicative of child abuse.
C. Bruises on a toddler's knees are a common finding in active children who are learning to walk and explore their environment. While bruises should always be assessed, they are not automatically indicative of child abuse.
D. An 8-month-old infant crying when a parent leaves the room is a normal separation anxiety response for an infant of this age and is not indicative of child abuse. This behavior is part of normal infant development.
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