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. Veracity: Veracity refers to the ethical principle of truthfulness or honesty. By informing the client about the potential adverse effects of transcranial magnetic stimulation (TMS) and reassuring them that it should not affect their memory, the nurse is demonstrating truthfulness and providing accurate information to the client.
B. Fidelity: Fidelity pertains to the ethical principle of faithfulness or honoring commitments and promises made to clients. While important, fidelity is not directly demonstrated in this scenario.
C. Beneficence: Beneficence involves the ethical principle of doing good or acting in the best interest of the client to promote their well-being. While providing information about the potential adverse effects of TMS is aligned with beneficence, the specific action described in the scenario focuses more on truthfulness (veracity).
D. Autonomy: Autonomy refers to the ethical principle of respecting the client's right to make their own decisions and choices regarding their healthcare. While autonomy is important in healthcare decision-making, it is not directly demonstrated in this scenario, as the nurse is providing information rather than facilitating the client's decision-making process.
Correct Answer is B
Explanation
A. Establish a new routine for the child to follow while in the facility. - Preschoolers thrive on routines and familiarity, especially in unfamiliar environments like acute care facilities. Therefore, it's essential for the nurse to maintain the child's existing routine as much as possible to provide a sense of security and stability.
B. Encourage the child to play with toys such as a pounding board. - Encouraging play with age-appropriate toys helps promote normalcy, reduce anxiety, and facilitate coping for preschoolers during their hospital stay. Toys like a pounding board provide opportunities for physical activity and engagement, which can help distract and entertain the child.
C. Use medical terminology when discussing procedures with the child. - Preschoolers have limited understanding of complex medical terminology. Using simple, age-appropriate language helps the child better comprehend what is happening, reducing fear and anxiety. Therefore, it's important for the nurse to avoid medical jargon and use language the child can understand.
D. Perform the morning assessments when the parent is not in the room. - Preschoolers often feel more comfortable and secure when their parents are present, especially in unfamiliar environments like hospitals. Performing assessments in the presence of the parent helps maintain the child's sense of security and allows the parent to participate in the child's care and provide comfort and support.
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