A nurse is assessing a 2-year-old toddler. Which of the following findings should the nurse expect?

Natural loss of deciduous teeth

Nontender, protruding abdomen

Palpable fontanels

Head circumference exceeds chest circumference

Answer and Explanation

The Correct Answer is B

A.   Incorrect. The natural loss of deciduous (baby) teeth typically begins around 6 years of age, not at 2 years old.
B.   Correct. Toddlers often have a nontender, protruding abdomen due to their underdeveloped abdominal muscles.
C.   Incorrect. The fontanels (soft spots on the baby's head) should be closed by 18-24 months of age. Palpable fontanels at 2 years old could indicate abnormal cranial development.
D.   Incorrect. It is not typical for a 2-year-old's head circumference to exceed their chest circumference. Head circumference is usually greater in infants but gradually becomes similar to chest circumference by 1-2 years of age.

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Correct Answer is B

Explanation

Among the given assessment findings, the one that warrants the most immediate intervention by the nurse is the shortness of breath on exertion. Shortness of breath on exertion in a client with a history of chronic obstructive pulmonary disease (COPD) and pneumonia indicates increased respiratory distress and compromised lung function. It suggests that the client is experiencing difficulty breathing even with minimal physical exertion. This finding may indicate worsening respiratory status, increased oxygen demand, and inadequate oxygenation. The nurse should take immediate action to address the shortness of breath, which may involve providing supplemental oxygen, initiating or adjusting bronchodilator medications, and monitoring the client's respiratory status closely. Prompt intervention is crucial to ensure adequate oxygenation and prevent respiratory failure.

While the other assessment findings (bilateral diffuse wheezing, temperature of 100.5 °F, and yellow expectorated sputum) are also important and require attention, the shortness of breath on exertion poses the greatest immediate risk and necessitates immediate intervention to address the client's respiratory distress.

A. Blow into the meter as hard and quickly as possible. B. Maintain a semi-Fowler's position during testing. C. Record the average of the readings. D. Place tongue on the mouthpiece of the meter.

Correct Answer is A

Explanation

A. Correct. The child should be instructed to blow into the peak expiratory flow meter as hard and quickly as possible to achieve maximal effort. This provides an accurate measure of peak expiratory flow, which is important in assessing asthma control.
B. Incorrect. The child's body position during testing does not typically affect the accuracy of peak expiratory flow measurements.
C. Incorrect. While recording the average of multiple readings over time is important, the child needs to understand how to perform a single accurate reading first.
D. Incorrect. The tongue is not usually involved in the use of a peak expiratory flow meter.
The child should place their lips tightly around the mouthpiece to create a seal while blowing forcefully into the device.

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A nurse is assessing a 2-year-old toddler. Which of the following findings should the nurse expect?

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Naxlex Comprehensive Predictor Exams

A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with pneumonia. Vital signs include: heart rate 122 beats/minute, respiratory rate 28 breaths/minute, and blood pressure 170/90 mmHg. Which assessment finding warrants the most immediate intervention by the nurse?

Correct Answer is B

Explanation

A nurse is instructing a school-age child who has asthma about the use of a peak expiratory flow meter. Which of the following instructions should the nurse include in the teaching?

Correct Answer is A

Explanation

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