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

Answer and Explanation

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.

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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.

A. "You should wear a snug-fitting bra continuously for 72 hours." B. "You should apply moist heat to your breasts four times per day." C. "You should limit your fluid intake to 1 liter per day." D. "You should manually express milk when engorgement occurs."

Correct Answer is A

Explanation

A. "You should wear a snug-fitting bra continuously for 72 hours": Wearing a snug-fitting bra continuously for 72 hours can help suppress lactation by providing support and reducing stimulation to the breasts. This can help prevent milk production and engorgement.
B. "You should apply moist heat to your breasts four times per day": Moist heat can stimulate milk production and should be avoided when trying to suppress lactation.
C. "You should limit your fluid intake to 1 liter per day": Adequate hydration is important for overall health, and limiting fluid intake to 1 liter per day is not advisable, especially postpartum when hydration needs may be higher.
D. "You should manually express milk when engorgement occurs": Manual expression of milk can stimulate milk production and should be avoided when attempting to suppress lactation. If engorgement occurs, cold compresses or ice packs can be used to reduce discomfort without stimulating milk production.

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A nurse is caring for four children in an emergency department. Which of the following clients should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is postpartum and expresses concern about how her preschool-age son will react to having a baby sister. Which of the following strategies should the nurse suggest?

Correct Answer is C

Explanation

A nurse is teaching about how to suppress lactation with a client who is postpartum and bottle feeding their newborn. Which of the following instructions should the nurse include in the teaching?

Correct Answer is A

Explanation

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