A nurse is caring for a 2-year-old male toddler in the emergency department.
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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is Choice B.
Choice A rationale
Reading a story every night is beneficial for cognitive and language development but does not specifically address the developmental task of autonomy versus shame and doubt, which is the focus for toddlers according to Erikson.
Choice B rationale
Allowing a toddler to pull a talking-duck toy fosters autonomy and independence, which are key aspects of Erikson’s developmental stage for toddlers. This activity encourages the child to explore and make choices independently.
Choice C rationale
Feeding the toddler his lunch does not promote autonomy. Instead, it may contribute to dependence, which is contrary to the developmental task of this age group.
Choice D rationale
Watching a puppet show on television is a passive activity that does not actively engage the child in developing autonomy or independence.
Correct Answer is D
Explanation
The correct answer is Choice D.
Choice A rationale
Temper tantrums are not a type of learning disability. They are a normal part of toddler development and are a way for toddlers to express frustration and assert independence.
Choice B rationale
Leaving the room while a tantrum is happening is not recommended. It is important for parents to stay calm and present, providing a safe environment for the child. Ignoring the tantrum while staying nearby can help the child learn to self-regulate.
Choice C rationale
Psychological consults are not typically necessary for temper tantrums. Temper tantrums are a normal part of development and usually decrease as the child learns to communicate and manage emotions better.
Choice D rationale
Temper tantrums are indeed the toddler’s attempt to gain control of a situation. Toddlers often have tantrums when they are unable to express their needs or when they are frustrated by their lack of control over their environment. Understanding this can help parents respond appropriately and support their child’s emotional development.
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