A nurse is caring for a toddler who has acute laryngotracheobronchitis and has been placed in a cool mist tent. Which of the following findings indicates that the treatment has been effective?
Barking cough
Decreased stridor
Improved hydration
Decreased temperature
The Correct Answer is B
Choice A: A barking cough is not a finding that indicates that the treatment has been effective, but rather a symptom of acute laryngotracheobronchitis, which is also known as croup. Croup is a condition that causes inflammation and narrowing of the upper airway and produces a characteristic barking or seal-like cough. A barking cough may persist for several days after the onset of croup and does not reflect the severity of the airway obstruction.
Choice B: Decreased stridor is a finding that indicates that the treatment has been effective, as stridor is a sign of airway obstruction caused by acute laryngotracheobronchitis. Stridor is a high-pitched, noisy breathing sound that occurs when the air passes through the narrowed airway. Stridor may be inspiratory, expiratory, or biphasic,
depending on the level of obstruction. Decreased stridor means that the airway is less obstructed and the child can breathe more easily.
Choice C: Improved hydration is not a finding that indicates that the treatment has been effective, but rather a goal of treatment for acute laryngotracheobronchitis. Dehydration can worsen the symptoms and complications of croup by thickening the mucus and increasing the risk of infection. Improved hydration can help thin out the mucus and prevent dehydration. Hydration can be improved by encouraging oral fluids, administering intravenous fluids, or providing humidified air.
Choice D: Decreased temperature is not a finding that indicates that the treatment has been effective, but rather a possible outcome of treatment for acute laryngotracheobronchitis. Fever may or may not be present in croup, depending on the cause and severity of the condition. Fever can be caused by viral or bacterial infection, inflammation, or dehydration. Decreased temperature can indicate that the infection or inflammation is resolving or that the dehydration is corrected.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C"]
Explanation
Choice A: Clubbing of the nail beds is not a finding that the nurse should expect in a child who has aortic stenosis, which is a condition that causes narrowing of the aortic valve and obstructs blood flow from the left ventricle to the aorta. Clubbing of the nail beds is a sign of chronic hypoxia, which can occur in conditions that affect the lungs or the right side of the heart.
Choice B: Murmur is a finding that the nurse should expect in a child who has aortic stenosis, as it indicates turbulent blood flow through the narrowed valve. A murmur can be heard with a stethoscope over the chest and may vary in intensity, pitch, and duration. A murmur caused by aortic stenosis is typically systolic, loud, and harsh and radiates to the neck or back.
Choice C: Weak pulses are a finding that the nurse should expect in a child who has aortic stenosis, as they indicate reduced blood flow and pressure in the peripheral arteries. Weak pulses can be felt with palpation of the radial, brachial, femoral, or pedal arteries and may be difficult to detect or absent.
Choice D: Bradycardia is not a finding that the nurse should expect in a child who has aortic stenosis, as it indicates a slow heart rate, which is less than 60 beats per minute in children. Bradycardia can occur in conditions that affect the electrical conduction system of the heart or cause increased vagal tone. A child who has aortic stenosis may have tachycardia, which is a fast heart rate, as a compensatory mechanism to increase cardiac output.
Choice E:Hypertension is not typically associated with aortic stenosis in children; instead, the condition often results in reduced blood pressure distal to the valve.
Correct Answer is B
Explanation
Choice A: A heart rate of 72/min is within the normal range for an adolescent, which is 60 to 100 beats per minute. A heart rate of 72/min does not indicate any signs of shock, hemorrhage, or cardiac injury. Therefore, this finding is not the nurse's priority.
Choice B: A blood pressure of 84/52 mm Hg is below the normal range for an adolescent, which is 110 to 120/70 to 80 mm Hg. A blood pressure of 84/52 mm Hg indicates hypotension, which can be a sign of shock, hemorrhage, or internal organ damage. Hypotension can lead to decreased tissue perfusion, organ failure, or death. Therefore, this finding is the nurse's priority and requires immediate intervention.
Choice C: An abdominal pain rated 4 on a scale of 0 to 10 is a moderate level of pain that can indicate inflammation, injury, or infection in the abdomen. However, pain is a subjective symptom that may vary depending on the individual and the severity of the condition. Pain can also be managed with analgesics or other measures. Therefore, this finding is not the nurse's priority.
Choice D: A respiratory rate of 20/min is within the normal range for an adolescent, which is 12 to 20 breaths per minute. A respiratory rate of 20/min does not indicate any signs of respiratory distress, hypoxia, or pulmonary injury. Therefore, this finding is not the nurse's priority.
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