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 mononucleosis and reports severe fatigue.
A child who has Wilms' tumor and an abdominal mass.
A child who has acute epiglottitis and is drooling.
A child who has a urinary tract infection and bright red blood in her urine.
The Correct Answer is C
Choice A rationale:
A child who has mononucleosis and reports severe fatigue requires medical attention, but this condition does not pose an immediate life-threatening risk compared to acute epiglottitis. Mononucleosis is a viral infection that can cause fatigue, sore throat, and swollen lymph nodes. While the child should be assessed, the priority is given to the child with acute epiglottitis due to the potential for airway obstruction and respiratory distress.
Choice B rationale:
A child who has Wilms' tumor and an abdominal mass also needs urgent medical evaluation. Wilms' tumor is a rare kidney cancer that primarily affects children. While it requires prompt attention, acute epiglottitis poses a more immediate threat to the airway and breathing.
Choice C rationale:
A child with acute epiglottitis and drooling requires immediate assessment and intervention. Acute epiglottitis is a potentially life-threatening infection that can cause severe swelling of the epiglottis, leading to airway obstruction. The child may have difficulty breathing and may present with the classic drooling sign due to the inability to swallow saliva. Prompt medical intervention, including airway management and appropriate antibiotics, is essential in this situation.
Choice D rationale:
A child with a urinary tract infection and bright red blood in her urine requires medical evaluation, but this condition is not as urgent as acute epiglottitis. Hematuria (blood in the urine) can have various causes, including urinary tract infections or kidney stones. While the child should receive medical attention, it does not take precedence over the immediate threat posed by acute epiglottitis, which requires urgent intervention to maintain the airway.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
a. Improves muscle strength.
Explanation:
Neostigmine is a medication used in the treatment of myasthenia gravis (MG). It belongs to a class of drugs called cholinesterase inhibitors. Neostigmine works by inhibiting the breakdown of acetylcholine, a neurotransmiter involved in muscle contraction. In MG, there is a decrease in the amount of acetylcholine available at the neuromuscular junction, leading to muscle weakness and fatigue.
By inhibiting the breakdown of acetylcholine, neostigmine helps to increase the concentration of acetylcholine at the neuromuscular junction. This, in turn, improves muscle strength and can alleviate the symptoms of weakness and fatigue associated with MG.
Option b, destroying the antibodies that cause MG, is not accurate. Myasthenia gravis is an autoimmune disorder characterized by the presence of antibodies that interfere with neuromuscular transmission.
Neostigmine does not directly target or eliminate these antibodies.
Option c, enhancing immune system function, is not accurate either. Neostigmine primarily acts on the neuromuscular junction to improve muscle strength and does not have a direct effect on immune system function.
Option d, preventing excessive coughing, is not the primary action of neostigmine. While increased muscle strength may indirectly improve respiratory function and reduce coughing in individuals with myasthenia gravis, it is not the primary indication or action of neostigmine.
Therefore, the most accurate information to include in teaching about neostigmine for a client with myasthenia gravis is that it improves muscle strength.
Correct Answer is C
Explanation
Choice C rationale:
The client's speech, "Tie a bow. Row the boat. Now I know. Whoa! I see you, yo," is an example of word salad. Word salad is a disorganized mixture of words and phrases that lack coherent meaning and logical connection. It is often observed in severe cases of schizophrenia or other mental health disorders and indicates a significant impairment in thought process and communication. In word salad, words and phrases are randomly juxtaposed, making it difficult to understand the intended message.
Choice A rationale:
Neologisms are newly coined words or phrases that have meaning only to the individual using them. Neologisms are often created by individuals with mental disorders and might not make sense to others. In the given speech, the words and phrases, although disorganized, are not newly coined or invented terms, so neologisms do not apply here. **
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.