A school nurse is caring for a child who has asthma and begins to have difficulty breathing. Which of the following actions should the nurse take?
Administer two puffs of albuterol.
Place the child in the supine position.
Encourage the use of a flutter mucus clearance device.
Instruct the child to perform controlled breathing exercises.
The Correct Answer is A
Choice A rationale:
Administer two puffs of albuterol. This is the correct answer because albuterol is a bronchodilator that helps to relieve acute asthma symptoms by opening up the airways. In a child experiencing difficulty breathing due to asthma, prompt administration of albuterol can help alleviate the symptoms and improve breathing.
Choice B rationale:
Place the child in the supine position. Placing the child in the supine position can further compromise their breathing, especially in a situation of asthma exacerbation. This position can restrict the airways and make breathing more difficult, so it is not an appropriate action.
Choice C rationale:
Encourage the use of a flutter mucus clearance device. While mucus clearance devices can be helpful for individuals with chronic respiratory conditions, such as cystic fibrosis, it is not the priority action for a child experiencing acute asthma symptoms. The immediate focus should be on relieving the airway constriction and addressing the breathing difficulty.
Choice D rationale:
Instruct the child to perform controlled breathing exercises. Controlled breathing exercises might be useful for anxiety and panic management, but in an acute asthma episode, the child's primary need is to open up the airways and improve breathing. Albuterol administration takes precedence over breathing exercises in this situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Perfectionistic behavior is not typically considered a behavioral finding indicative of sexual abuse in a school-age child. Perfectionism may be related to personality traits, family dynamics, or individual tendencies, but it is not a specific behavioral marker for sexual abuse.
Choice B rationale:
Manipulative behavior is not a specific indicator of sexual abuse in a school-age child. Children can display manipulative behavior for various reasons, including seeking attention or attempting to control situations. While behavioral changes can occur in response to trauma, manipulative behavior alone does not necessarily point to sexual abuse.
Choice C rationale:
Withdrawn behavior is a possible indication of sexual abuse in a school-age child. Sexual abuse can cause emotional and psychological distress in children, leading them to withdraw from social interactions. They might become isolated, exhibit changes in their usual behavior, and show decreased interest in activities they previously enjoyed.
Choice D rationale:
Destructive behavior is not a prominent behavioral finding associated specifically with sexual abuse in a school-age child. Destructive behaviors can arise from a range of factors, including emotional difficulties, behavioral disorders, or reactions to stressors. While trauma like sexual abuse can influence behavior, it's not a defining characteristic of sexual abuse in isolation.
Correct Answer is B
Explanation
Choice A rationale:
The Rotavirus vaccine is typically administered to infants, usually starting at 2 months of age, to protect against severe diarrhea and vomiting caused by rotavirus infection. However, the child in question is 11 years old, and the rotavirus vaccine is not recommended for administration at this age. The vaccine's protection window is within the infant and early childhood period, and the child would likely have received this vaccine earlier.
Choice B rationale:
Haemophilus influenzae type b (Hib) Hib vaccine is recommended as a series of doses to protect against Haemophilus influenzae type B infection, which can lead to severe illnesses like meningitis and pneumonia. While the child may have received this vaccine in infancy, a booster dose is often recommended around age 11 to ensure ongoing protection. This choice is correct for the given age group.
Choice C rationale:
Hepatitis A Hepatitis A vaccine is typically administered in two doses, with the first dose given at age 1 and the second dose administered at least 6 months later. The child in question is 11 years old, and assuming the child received the vaccine as per the standard schedule, there would be no need to administer this vaccine again.
Choice D rationale:
Human papillomavirus (HPV) HPV vaccine is recommended for adolescents to protect against several strains of the human papillomavirus that can lead to various cancers later in life. It's usually administered in a series of doses starting around age 11 or 12. However, the prompt states that the child is already up-to-date with current immunizations, and if the child received the HPV vaccine at the appropriate age, there would be no need for another dose at this time.
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