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 C
Explanation
A. Respiratory
Kawasaki disease primarily affects the cardiovascular system rather than the respiratory system. While respiratory symptoms such as cough or congestion may occur in some cases, they are not the primary focus of the disease.
B. Gastrointestinal
Although gastrointestinal symptoms such as abdominal pain, vomiting, or diarrhea can occur in Kawasaki disease, they are not the primary system affected. Gastrointestinal symptoms are considered part of the systemic manifestations of the disease but do not define its primary pathology.
C. Cardiovascular
This is the correct answer. Kawasaki disease primarily affects the cardiovascular system. It is characterized by inflammation of the blood vessels, particularly the medium-sized arteries, including the coronary arteries. Coronary artery involvement can lead to coronary artery aneurysms and other cardiovascular complications, making the cardiovascular system the primary focus of the disease.
D. Integumentary
The integumentary system (skin) is not primarily affected by Kawasaki disease. While changes in the skin, such as a rash, may occur as part of the systemic manifestations of the disease, they are not the primary focus of Kawasaki disease.
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.
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