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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale:
Contact precautions are indicated when the client has a condition that can be easily transmitted through direct contact with the client or their environment. Measles, which is an airborne disease, requires more stringent precautions due to its mode of transmission.
Choice B rationale:
The correct choice. Measles is spread through airborne particles, making airborne precautions necessary. These precautions include placing the client in a negative pressure room, wearing appropriate respiratory protection (e.g., N95 mask), and ensuring that healthcare providers are properly protected from inhaling infectious particles.
Choice C rationale:
A protective environment is a specialized form of isolation used for clients with compromised immune systems, such as those undergoing stem cell transplants. It involves maintaining a sterile environment to prevent the introduction of pathogens. This level of precautions is not applicable to clients with measles.
Choice D rationale:
Droplet precautions are appropriate for diseases that are transmitted through respiratory droplets generated by coughing, sneezing, or talking. Measles, however, is transmitted through smaller airborne particles that can remain suspended in the air for longer periods, making airborne precautions the most suitable choice.

A. Perfectionistic. B. Manipulative. C. Withdrawn. D. Destructive.

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.

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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?

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