A nurse is caring for four children in an emergency department. Which of the following clients should the nurse assess first?
A child who has acute epiglottitis and is drooling
A child who has mononucleosis and reports severe fatigue
A child who has Wilms' tumor and an abdominal mass
A child who has a urinary tract infection and bright red blood in their urine
The Correct Answer is A
A. A child who has acute epiglottitis and is drooling: Acute epiglottitis is a medical emergency that can rapidly progress to airway obstruction and respiratory distress. Drooling is a significant sign of airway compromise in children with epiglottitis due to swelling of the epiglottis. This child requires immediate assessment and intervention to ensure airway patency.
B. A child who has mononucleosis and reports severe fatigue: While mononucleosis can cause severe fatigue, it is not an immediate life-threatening condition compared to acute epiglottitis. Assessment and intervention for severe fatigue can be prioritized after addressing the child with potential airway compromise.
C. A child who has Wilms' tumor and an abdominal mass: Wilms' tumor is a type of kidney cancer that typically presents with an abdominal mass. While it requires timely medical intervention, it is not as urgent as acute epiglottitis, which poses a risk of airway obstruction.
D. A child who has a urinary tract infection and bright red blood in their urine: While a urinary tract infection with hematuria requires assessment and treatment, it is not immediately life-threatening compared to acute epiglottitis. Addressing the child with potential airway compromise takes precedence over evaluating and managing hematuria.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Adding water to the formula will decrease its osmolarity, reducing the risk of hyperosmolar dehydration. This action helps to dilute the formula and make it more isotonic, which is better tolerated by the client's gastrointestinal tract.
B. Repositioning the NG tube may be necessary if there are issues with tube placement or if the tube has migrated. However, it is not directly related to addressing hyperosmolar dehydration.
C. Increasing the rate of formula delivery may exacerbate hyperosmolar dehydration by introducing more concentrated formula into the gastrointestinal tract, leading to further dehydration.
D. Switching to a lactose-free formula may be appropriate if the client has lactose intolerance, but it does not address the issue of hyperosmolar dehydration. Adding water to the formula is the more appropriate intervention in this scenario to decrease osmolarity and prevent dehydration.
Correct Answer is C
Explanation
A. "Hold your daughter when your son first meets her." While it is important for the mother to hold the newborn during the first meeting with the older sibling, this option does not directly address the preschool-age son's potential reaction to the new baby.
B. "Plan for your son to meet his sister for the first time at home." Planning for the first meeting to occur at home is a common and appropriate strategy to help ease the transition for the older sibling. However, this option does not provide a specific strategy for helping the preschool-age son adjust to having a new sister.
C. "Give your son a little gift from his new sister." This is the most appropriate strategy to suggest. Offering a small gift from the new baby sister can help the preschool-age son feel included and special, fostering positive feelings toward the new sibling.
D. "Give your son plenty of 'alone time' with his sister." While encouraging bonding time between siblings is important, giving the older sibling plenty of alone time with the new baby may not be practical or feasible, especially in the early postpartum period when the mother requires assistance with caring for the newborn. Moreover, this option does not address the son's potential feelings of adjustment to having a new sister.
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