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.
|
Intervention |
|
|
Immune |
a. Administer acetaminophen b. Have the child wear a mask c. Administer a dose of montelukast d. Encourage oral fluids |
|
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 B
Explanation
Choice A reason:
Blurred vision: While blurred vision can occur in some cases of meningitis, it is not one of the most common or definitive symptoms. Meningitis primarily affects the meninges, leading to symptoms like headache, fever, and neck stiffness. Blurred vision might be a secondary symptom due to increased intracranial pressure, but it is not as typical as other symptoms.
Choice B reason:
Severe headache: A severe headache is a hallmark symptom of meningitis. This headache is often described as intense and different from typical headaches. It is caused by the inflammation of the meninges, which are the protective membranes covering the brain and spinal cord. The headache is usually accompanied by other symptoms such as fever, neck stiffness, and sensitivity to light.
Choice C reason:
Oriented to person, place, and year: Being oriented to person, place, and year indicates normal cognitive function. However, meningitis can cause confusion, altered mental status, and even loss of consciousness in severe cases. Therefore, this finding would not be expected in a client with meningitis.
Choice D reason:
Bradycardia: Bradycardia, or a slow heart rate, is not typically associated with meningitis. Meningitis symptoms are more related to the central nervous system and include fever, headache, neck stiffness, and altered mental status. Bradycardia might occur in other conditions but is not a common finding in meningitis.
Correct Answer is B
Explanation
Choice A reason:
Restricting the client’s oral fluid intake is not appropriate in this situation. Adequate fluid intake is essential to help flush out the bladder and prevent clot formation. Clients are usually encouraged to drink plenty of fluids to ensure proper hydration and urine flow.
Choice B reason:
Reminding the client that he might feel a constant urge to void is important. After a transurethral resection of the prostate (TURP), the presence of the catheter and continuous bladder irrigation can cause a sensation of needing to urinate. This is a common experience and reassuring the client helps manage their expectations and reduce anxiety.
Choice C reason:
Weighing the client every evening is not a standard intervention specifically related to TURP and continuous bladder irrigation. While monitoring weight can be important for overall health, it is not directly related to the immediate postoperative care of a TURP patient.
Choice D reason:
Monitoring the client’s urine output every 6 hours is important, but it should be done more frequently in the immediate postoperative period. Continuous bladder irrigation requires close monitoring to ensure that the irrigation fluid is flowing properly and that there are no blockages or complications.
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.