A school nurse is caring for a school-age child who has asthma.
Click to highlight the intervention the nurse should take. To deselect a finding, click on the finding again.
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Intervention |
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Immune |
a. Administer acetaminophen b. Have the child wear a mask c. Administer a dose of montelukast d. Encourage oral fluids |
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Respiratory |
a. Administer albuterol nebulizer b. Evaluate the child’s peak flow c. Initiate chest percussions d. Have the child sit upright in a position of comfort |
Administer acetaminophen
Have the child wear a mask
Administer a dose of montelukast
Encourage oral fluids
Administer albuterol nebulizer
Evaluate the child’s peak flow
Initiate chest percussions
Have the child sit upright in a position of comfort
The Correct Answer is ["A","E"]
Choice A Reason: Administer acetaminophen
Administering acetaminophen is a common intervention for reducing fever. In this case, the child’s temperature has risen significantly from 37.3°C (99.1°F) at 0900 to 39.9°C (103.8°F) at 1300. A fever of 39.9°C is considered high and can cause discomfort and other complications if not managed. Acetaminophen is an antipyretic medication that helps lower body temperature and provides relief from fever. It is important to monitor the child’s temperature and ensure it returns to a normal range, which is typically around 36.5°C to 37.5°C (97.7°F to 99.5°F) for school-age children.
Choice B Reason: Have the child wear a mask
Having the child wear a mask is a preventive measure to reduce the spread of respiratory infections. While this intervention is important in certain contexts, such as during flu season or in the presence of contagious illnesses, it is not directly related to managing an acute asthma exacerbation. Masks can help prevent the spread of infections, but they do not address the immediate respiratory distress and wheezing observed in the child. Therefore, this choice is not the most appropriate intervention for the current situation.
Choice C Reason: Administer a dose of montelukast
Montelukast is a leukotriene receptor antagonist used for long-term management of asthma and allergic rhinitis. It helps reduce inflammation and prevent asthma attacks. However, montelukast is not typically used for immediate relief during an acute asthma exacerbation. It is more effective as a maintenance medication taken regularly to control chronic asthma symptoms. In this scenario, the child requires immediate relief from respiratory distress, making montelukast an inappropriate choice for acute intervention.
Choice D Reason: Encourage oral fluids
Encouraging oral fluids is a supportive measure to ensure the child remains hydrated. Hydration is important for overall health and can help thin mucus secretions, making it easier for the child to breathe. However, while hydration is beneficial, it is not the primary intervention needed to address the acute respiratory distress and wheezing observed in the child. Therefore, this choice alone is not sufficient to manage the current asthma exacerbation.
Respiratory system
Choice A Reason: Administer albuterol nebulizer
Administering an albuterol nebulizer is the most appropriate intervention for managing an acute asthma exacerbation. Albuterol is a short-acting beta-agonist that works by relaxing the muscles around the airways, allowing them to open up and improve airflow. This medication provides quick relief from symptoms such as wheezing, shortness of breath, and chest tightness. In this case, the child is experiencing respiratory distress and wheezing, making albuterol the most effective choice for immediate relief. The normal respiratory rate for school-age children is 18-25 breaths per minute, and the child’s rate of 26 breaths per minute indicates respiratory distress.
Choice B Reason: Evaluate the child’s peak flow
Evaluating the child’s peak flow involves measuring the maximum speed at which the child can exhale. This assessment helps determine the severity of the asthma exacerbation and the effectiveness of the treatment. Peak flow measurements can guide clinical decisions and adjustments to the child’s asthma management plan. However, during an acute asthma attack, the priority is to provide immediate relief from symptoms. While peak flow evaluation is valuable for ongoing asthma management, it is not the primary intervention needed to address the acute respiratory distress and wheezing observed in the child.
Choice C Reason: Initiate chest percussions
Initiating chest percussions involves rhythmic tapping on the chest to help loosen and mobilize mucus in the airways. This technique can be beneficial for individuals with conditions that cause excessive mucus production, such as cystic fibrosis. However, in the context of an acute asthma exacerbation, the primary concern is bronchoconstriction and inflammation, not mucus clearance. The child requires interventions that directly address airway constriction, such as bronchodilators. Therefore, while chest percussions may be helpful in certain situations, they are not the most appropriate intervention for managing acute asthma symptoms.
Choice D Reason: Have the child sit upright in a position of comfort
Having the child sit upright in a position of comfort can help improve breathing by allowing the lungs to expand more fully. This position can reduce the work of breathing and provide some relief from respiratory distress. While this intervention is supportive and can be beneficial, it is not sufficient on its own to manage an acute asthma exacerbation. The child requires pharmacological interventions, such as bronchodilators, to relieve bronchoconstriction and improve airflow. Therefore, while sitting upright is helpful, it should be combined with other interventions for optimal management of acute asthma symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
Distorted perceptual field is more commonly associated with severe anxiety or panic attacks rather than moderate anxiety. In severe anxiety, a person’s ability to perceive reality can be significantly impaired, leading to distorted perceptions and an inability to focus.
Choice B reason:
Urinary frequency can be a symptom of anxiety, but it is not specifically indicative of moderate anxiety. It can occur in various levels of anxiety, including mild, moderate, and severe. However, it is not as prominent a symptom as others like rapid speech or restlessness.
Choice C reason:
Rapid speech is a common symptom of moderate anxiety. Individuals with moderate anxiety often exhibit signs of increased nervousness and agitation, which can manifest as rapid or pressured speech. This symptom reflects the heightened state of arousal and the difficulty in controlling anxious thoughts.
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"}}
Explanation
Choice A: Ice packs to affected area 15 minutes on, 15 minutes off
Reason: Ice packs are generally contraindicated for patients with sickle cell disease (SCD). The use of ice packs can cause vasoconstriction, which narrows blood vessels and reduces blood flow. This can exacerbate the pain and potentially trigger a vaso-occlusive crisis (VOC) by further restricting blood flow to the already compromised areas. Studies have shown that cold exposure can worsen pain in SCD patients, making ice packs an unsuitable option.
Choice B: Intravenous fluids (IVF) at maintenance rate
Reason: Intravenous fluids are anticipated for patients with SCD, especially during a pain crisis. Hydration is crucial as it helps to reduce the viscosity of the blood, thereby improving blood flow and reducing the likelihood of sickling. Adequate hydration can help to alleviate pain and prevent further complications. The administration of IV fluids is a standard practice in managing acute pain episodes in SCD patients.
Choice C: Ketorolac IV for pain
Reason: Ketorolac, a nonsteroidal anti-inflammatory drug (NSAID), is anticipated for managing pain in SCD patients. It provides effective pain relief without the risks associated with opioids, such as respiratory depression and dependence. Ketorolac works by inhibiting the production of prostaglandins, which are involved in the inflammatory process and pain signaling. It is particularly useful for acute pain management in SCD patients.
Choice D: Ambulate in hallway with supervision
Reason: Ambulation during a pain crisis is generally contraindicated for SCD patients. Movement can increase pain and stress on the affected areas, potentially worsening the condition. During a VOC, patients are often advised to rest and avoid activities that could exacerbate the pain. While physical activity is important for overall health, it should be carefully managed and avoided during acute pain episodes.
Choice E: Meperidine IV for pain
Reason: Meperidine is contraindicated for pain management in SCD patients due to its potential for serious side effects. Meperidine can accumulate in the body and produce a toxic metabolite called normeperidine, which can cause seizures and other adverse effects. Additionally, meperidine is less effective than other opioids and has a higher risk of causing dependency and other complications. Therefore, it is not recommended for managing pain in SCD patients.
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