A nurse is caring for a 3-year-old child.
Exhibit 1
Exhibit 2 Nurses' Notes
0730:
Child presents to the emergency department (ED). Guardians report the child woke up coughing with a low-grade fever. Child appears alert and restless in guardian's arms.
Respirations easy, no cough noted.
0800:
Child became agitated. Hoarse cry noted with audible inspiratory stridor. Barking, nonproductive cough present.
For each of the following findings, click to specify if the finding is consistent with acute laryngotracheobronchitis or pneumonia. Each finding may support more than one disease process.
Assessment Findings: Acute laryngotracheobronchitis /Pneumonia
Irritability
Temperature
Cough findings at 0800
Stridor
The Correct Answer is A
A. This finding is consistent with both acute laryngotracheobronchitis and pneumonia, as both conditions can cause discomfort and distress in children.
B. Fever can be present in both acute laryngotracheobronchitis and pneumonia as they are both infections of the respiratory tract. It is a non-specific symptom that can occur with various respiratory illnesses.
C. This finding is more consistent with acute laryngotracheobronchitis than pneumonia, as acute laryngotracheobronchitis is characterized by a barking, non-productive cough that worsens at night or with agitation, while pneumonia causes a productive cough that may be accompanied by chest pain or difficulty breathing.
D. This finding is more consistent with acute laryngotracheobronchitis than pneumonia, as acute laryngotracheobronchitis causes inflammation and narrowing of the upper airway, leading to a high-pitched sound during inhalation, while pneumonia affects the lower airway and does not usually cause stridor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Examining the child for skin irritation at the cast edges is important to prevent complications, but it is not the priority over monitoring for circulation and potential complications.
B. Restricting strenuous activities is important for preventing damage to the cast, but it is not the priority over monitoring for circulatory compromise.
C. Monitoring for pallor or swelling in the child's affected hand is the priority because it indicates potential circulatory compromise, which is a critical concern following cast application.
D. Using a hair dryer on a cool setting to relieve itching is a helpful suggestion, but it is not the priority over monitoring for potential complications.
Correct Answer is C
Explanation
Correct Answer: C Rationale:
A. Vomiting may occur with various gastrointestinal conditions but is not a specific finding associated with necrotizing enterocolitis. Bloody stools are more characteristic of this condition.
B. Hypertension is not typically associated with necrotizing enterocolitis. Instead, infants may present with hypotension due to sepsis or shock.
C. A rounded abdomen is a common finding in necrotizing enterocolitis due to abdominal distention from gas and fluid accumulation in the intestines.
D. Tachypnea may occur as a result of sepsis or respiratory distress but is not specific to necrotizing enterocolitis.
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