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A nurse is caring for a 2-year-old male toddler in the emergency department.

Exhibits

Which of the following findings should the nurse identify as an indication that the treatment plan is effective? (Select all that apply.)

Nasal flaring

Retractions

Oxygen saturation

Breath sounds in bilateral bases

Respiratory rate

Heart rate

Answer and Explanation

Correct Answer : C,D,E

Choice A rationale:

Nasal flaring is a sign of respiratory distress. The absence of nasal flaring would indicate improvement, but the presence of nasal flaring indicates ongoing respiratory distress.

Choice B rationale:

Retractions are also a sign of respiratory distress. The reduction or absence of retractions would indicate improvement, but their presence indicates ongoing respiratory distress.

Choice C rationale:

Oxygen saturation is a key indicator of respiratory function. An improvement in oxygen saturation levels (from 89% on room air to higher levels) indicates that the treatment plan is effective in improving the child’s oxygenation.

Choice D rationale:

Breath sounds in bilateral bases are important to assess for improvement in lung function. The presence of clear breath sounds or reduced wheezing indicates improvement in the child’s respiratory status.

Choice E rationale:

Respiratory rate is an important vital sign to monitor in respiratory conditions. A decrease in respiratory rate (from 42 breaths/min to a lower rate) indicates that the treatment plan is effective in reducing the child’s respiratory distress.

Choice F rationale:

Heart rate can be influenced by various factors, including fever, anxiety, and respiratory distress. While a decrease in heart rate may indicate improvement, it is not as specific an indicator of respiratory function as oxygen saturation and respiratory rate.

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Correct Answer is C

Explanation

The correct answer is Choice C.

Choice A rationale

Failure to thrive is a condition where a child does not gain weight or grow as expected. While severe diarrhea can contribute to failure to thrive, the immediate concern in this scenario is the significant weight loss indicating severe dehydration.

Choice B rationale

Malabsorption syndrome involves the inability to absorb nutrients properly, leading to malnutrition and weight loss. However, the acute weight loss in this case is more indicative of severe dehydration.

Choice C rationale

Severe dehydration is characterized by significant fluid loss, which can be life-threatening in infants. The weight loss from 11 pounds to 9 pounds, 8 ounces indicates a substantial fluid loss, pointing to severe dehydration.

Choice D rationale

Risk for fluid volume deficit is a potential diagnosis, but the significant weight loss and clinical presentation indicate that the infant is already experiencing severe dehydration.

A. Daytime symptoms occur more than twice a week. B. Nighttime symptoms occur approximately twice a month. C. Minor limitations occur with normal activity. D. Symptoms are continuous throughout the day. E. Peak expiratory flow (PEF) is greater than or equal to 80% of the predicted value.

Correct Answer is ["A","C","E"]

Explanation

The correct answers are Choices A, C, and E.

Choice A rationale

Daytime symptoms occurring more than twice a week is an expected finding in mild persistent asthma. This indicates that the asthma is not well-controlled and requires regular use of a controller medication.

Choice B rationale

Nighttime symptoms occurring approximately twice a month is more characteristic of intermittent asthma, not mild persistent asthma.

Choice C rationale

Minor limitations with normal activity are expected in mild persistent asthma. This indicates that the asthma is affecting the child’s daily activities to some extent.

Choice D rationale

Symptoms that are continuous throughout the day are indicative of severe persistent asthma, not mild persistent asthma.

Choice E rationale

A peak expiratory flow (PEF) greater than or equal to 80% of the predicted value is an expected finding in mild persistent asthma. This indicates that the child’s lung function is relatively well-preserved. .

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A nurse is caring for a 2-year-old male toddler in the emergency department. Exhibits Which of the following findings should the nurse identify as an indication that the treatment plan is effective? (Select all that apply.)

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A nurse is caring for a 2-year-old male toddler in the emergency department.

Exhibits

Which of the following findings should the nurse identify as an indication that the treatment plan is effective? (Select all that apply.)