A nurse is caring for a toddler who has laryngotracheobronchitis. For which of the following findings should the nurse monitor to detect airway obstruction?
Decreased stridor
Increased restlessness
Decreased heart rate
Decreased temperature
The Correct Answer is B
A. Decreased stridor: Stridor is a high-pitched, noisy breathing sound caused by turbulent airflow through a narrowed or partially obstructed airway. In laryngotracheobronchitis, stridor is often present and may worsen with increasing airway obstruction. Therefore, decreased stridor would not be a typical finding associated with airway obstruction in this condition.
B. Increased restlessness: Increased restlessness can be a sign of worsening respiratory distress and impending airway obstruction. As the child struggles to breathe, they may become increasingly agitated and restless, indicating the need for prompt intervention to ensure adequate oxygenation.
C. Decreased heart rate: Decreased heart rate (bradycardia) is not typically associated with airway obstruction in laryngotracheobronchitis. In fact, the heart rate may increase as a compensatory response to hypoxia and respiratory distress.
D. Decreased temperature: Changes in temperature are not typically associated with airway obstruction in laryngotracheobronchitis. The focus of monitoring in this condition is primarily on respiratory distress and signs of worsening airway obstruction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. A 45-degree head elevation: This position can help facilitate venous drainage and reduce intracranial pressure. Elevating the head of the bed may aid in preventing the accumulation of cerebrospinal fluid (CSF) in the brain, which is important after VP shunt insertion to maintain proper drainage. However, this position alone may not be sufficient.
B. On the nonoperative side: Placing the child on the nonoperative side can help reduce pressure on the side where the shunt was inserted, minimizing discomfort and the risk of disruption or displacement of the shunt. However, this position may not directly affect CSF drainage.
C. Prone: Placing the child prone (lying face down) is generally not recommended after VP shunt insertion. This position may increase pressure on the head and interfere with proper CSF drainage, potentially leading to complications.
D. Supine: Placing the child supine (lying on their back) is typically recommended after VP shunt insertion. This position helps promote proper drainage of CSF through the shunt system without placing undue pressure on the surgical site. It also allows for easy monitoring of the child's condition and surgical site.
Correct Answer is B
Explanation
A. Pulmonary function test:
Pulmonary function tests (PFTs) assess lung function by measuring airflow, lung volume, and gas exchange. While PFTs can provide valuable information about respiratory function, they are not specific to cystic fibrosis and may show abnormalities consistent with various respiratory conditions. However, PFTs are often performed in individuals with cystic fibrosis to monitor lung function over time and assess response to treatment. They are not considered the most definitive test for diagnosing cystic fibrosis.
B. Sweat chloride test:
This option is correct. The sweat chloride test is considered the most definitive diagnostic test for cystic fibrosis. It measures the concentration of chloride in sweat, which is typically elevated in individuals with cystic fibrosis due to defective chloride transport in sweat glands. A sweat chloride concentration above a certain threshold (usually ≥60 mmol/L) is diagnostic of cystic fibrosis, particularly when confirmed with repeat testing.
C. Stool fat content analysis:
Stool fat content analysis evaluates fat absorption and fecal fat excretion, which may be impaired in individuals with cystic fibrosis due to pancreatic insufficiency. However, while stool fat content analysis can provide supportive evidence of malabsorption in cystic fibrosis, it is not considered the most definitive test for diagnosing the condition. Stool fat content analysis is often used in conjunction with other diagnostic tests to assess pancreatic function and nutritional status in individuals with cystic fibrosis.
D. Sputum culture:
Sputum culture involves culturing respiratory secretions to identify bacterial pathogens, which can be useful for diagnosing respiratory infections in individuals with cystic fibrosis. However, sputum culture is not specific to cystic fibrosis and may show similar findings in other respiratory conditions. While respiratory cultures are important for guiding treatment in cystic fibrosis, they are not considered the most definitive test for diagnosing the condition.
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