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 D
Explanation
A. Suggest that the client attend adult day care three times per week: While adult day care can provide socialization opportunities and supervision for older adults, it may not be suitable for all clients, especially those who are still independent and prefer to live in their own homes. Additionally, attending adult day care may not directly address the client's diabetes management needs.
B. Review assisted living accommodations with the client: Assisted living accommodations are typically considered for individuals who require assistance with activities of daily living (ADLs) or who can no longer live independently. Since the client in this scenario lives independently, reviewing assisted living accommodations may not be appropriate at this time.
C. Discuss a long-term care referral for the client with the provider: Long-term care referrals are generally reserved for individuals who require ongoing assistance with ADLs and medical care that cannot be adequately provided in a home setting. Since the client is currently living independently and managing their diabetes, a long-term care referral may not be necessary.
D. Instruct the client about the use of telehealth services: This is the most appropriate intervention for the client in a rural area who may have limited access to healthcare resources. Telehealth services can provide remote monitoring, education, and support for managing diabetes while allowing the client to remain in their home environment. This intervention promotes independence and supports the client's ability to manage their condition effectively while living in a rural area.
Correct Answer is C
Explanation
A. Hazelnuts: While hazelnuts are a common allergen, they are not typically associated with cross-sensitivity to latex. Therefore, further assessment for cross-sensitivity to hazelnuts is not necessary based solely on the child's latex allergy.
B. Almonds: Similar to hazelnuts, almonds are a common allergen but are not typically associated with cross-sensitivity to latex. Therefore, further assessment for cross-sensitivity to almonds is not necessary based solely on the child's latex allergy.
C. Bananas: Bananas are one of the most common foods associated with latex allergy cross-sensitivity. Many individuals with latex allergy may also experience allergic reactions to bananas due to shared allergenic proteins. Therefore, further assessment for cross-sensitivity to bananas is warranted in this case.
D. Strawberries: While strawberries are a common allergen, they are not typically associated with cross-sensitivity to latex. Therefore, further assessment for cross-sensitivity to strawberries is not necessary based solely on the child's latex allergy.
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