A patient is admitted from the emergency room with laryngotracheobronchitis. The patient has a brassy cough, stridor, and substernal retractions. The child is receiving an intravenous infusion and is placed in a mist tent. Which observation would indicate a worsening of the patient's condition?
An increasing pulse rate.
Mouth breathing.
An increase in nasal discharge.
A hoarse cry.
The Correct Answer is A
Choice A rationale:
An increasing pulse rate suggests that the patient's condition is worsening. Tachycardia can indicate increased work of breathing and decreased oxygenation, which are concerning signs in laryngotracheobronchitis.
Choice B rationale:
Mouth breathing is a common response to airway obstruction, such as in laryngotracheobronchitis. While it indicates respiratory distress, it doesn't specifically suggest a worsening of the condition.
Choice C rationale:
An increase in nasal discharge might be seen with the common cold or other upper respiratory infections but is not a specific indicator of worsening laryngotracheobronchitis.
Choice D rationale:
A hoarse cry is a characteristic symptom of laryngotracheobronchitis due to inflammation of the airway. However, it is a common initial symptom and may not directly correlate with worsening of the condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Allowing the patient to stay in the chosen position might not be the best approach, as the child's preference might not align with therapeutic considerations for managing status asthmaticus.
Choice B rationale:
Semi-Fowler's position, with the head of the bed elevated, promotes improved lung expansion and easier breathing for patients with respiratory distress. Explaining the rationale behind this position to the child helps them understand its therapeutic benefits, encouraging compliance.
Choice C rationale:
Demonstrating various positions could confuse the child and delay appropriate intervention. A clear explanation of the preferred position is more effective in this critical situation.
Choice D rationale:
Removing pillows might be counterproductive, as elevating the head of the bed is beneficial for respiratory distress. This choice contradicts the therapeutic goal.
Correct Answer is B
Explanation
Choice A rationale:
Strict isolation should begin immediately after exposure. This choice is incorrect because chickenpox does not require strict isolation immediately after exposure. The incubation period of chickenpox is about 10-21 days, during which communicability has not yet begun.
Choice B rationale:
Communicability begins prior to the eruption of lesions. This choice is correct. Chickenpox is highly contagious, and individuals can transmit the virus to others even before the characteristic skin lesions appear. This understanding is crucial for appropriate room assignment to prevent the spread of the virus to other patients.
Choice C rationale:
Strict isolation should begin as soon as the skin lesions erupt. This choice is incorrect. While isolation precautions are necessary for patients with active chickenpox lesions, waiting until the lesions erupt is not sufficient to prevent transmission, as communicability starts before this stage.
Choice D rationale:
Communicability begins 14 days after exposure. This choice is incorrect. The correct timing for the onset of communicability is much earlier than 14 days after exposure. Waiting until this point for isolation would not effectively prevent transmission.
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