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 C
Explanation
Choice A: Reducing environmental stimuli can help decrease the discomfort and agitation of a child who has meningitis, as they may experience headache, photophobia, and neck stiffness. However, this action is not the priority, as it does not address the cause of the infection or prevent complications.
Choice B: Documenting intake and output can help monitor the fluid balance and hydration status of a child who has meningitis, as they may have fever, vomiting, and decreased oral intake. However, this action is not the priority, as it does not address the cause of the infection or prevent complications.
Choice C: Administering antibiotics when available can help treat the bacterial infection that causes meningitis and prevent serious complications such as brain damage, hearing loss, or death. This action is the priority, as it can save the child's life and improve their outcome.
Choice D: Maintaining seizure precautions can help protect the child from injury and provide safety measures in case of a seizure, as meningitis can cause increased intracranial pressure and seizures. However, this action is not the priority, as it does not address the cause of the infection or prevent complications.
Correct Answer is D
Explanation
Choice A: Loosening restrictive clothing is not the priority action, but rather a secondary action for a child who is having a tonic-clonic seizure and vomiting. A tonic-clonic seizure is a type of seizure that involves the stiffening of muscles (tonic phase) followed by jerking movements (clonic phase). Loosening restrictive clothing can prevent injury or discomfort to the child during or after the seizure.
Choice B: Placing a pillow under the child's head is not the priority action, but rather an inappropriate action for a child who is having a tonic-clonic seizure and vomiting. A pillow under the head can obstruct the airway or cause aspiration of vomitus into the lungs. The nurse should remove any pillows or objects from around the head and neck area and support the head with their hands or on a flat surface.
Choice C: Clearing the area of hazards is not the priority action, but rather a secondary action for a child who is having a tonic-clonic seizure and vomiting. Clearing the area of hazards can prevent injury or harm to the child or others during or after the seizure. The nurse should remove any sharp, hard, or flammable objects from near or under the child and move any furniture or equipment away.
Choice D: Positioning the child side-lying is the priority action for a child who is having a tonic-clonic seizure and vomiting, as it can protect the airway and prevent aspiration of vomitus into the lungs. Aspiration can cause pneumonia, which is an infection of the lungs that can cause fever, cough, difficulty breathing, or death. The nurse should turn the child's head to one side and place them on their side with their knees bent and one arm under their head. The nurse should also suction any vomitus from their mouth and nose if needed.
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