In assessing a 2-year-old boy with croup, the practical nurse (PN) finds that he has become increasingly irritable and has developed tachypnea and resting stridor. Which intervention is best for the PN to implement?
Instruct the mother to play with the child for stimulation and distraction.
Administer a dose of acetaminophen as needed.
Monitor the child's oxygen saturation level via pulse oximetry.
Encourage the child to drink adequate amounts of fluids.
The Correct Answer is C
Croup is a respiratory infection that causes inflammation and narrowing of the airway, resulting in a barking cough, hoarseness, and stridor. The PN should monitor the child's oxygen saturation level via pulse oximetry, as it can indicate the severity of the airway obstruction and the need for supplemental oxygen or other interventions.
The other options are not correct because:
A. Instructing the mother to play with the child for stimulation and distraction may worsen the child's condition, as it can increase his respiratory demand and anxiety.
B. Administering a dose of acetaminophen as needed may help reduce fever or pain, but it does not address the underlying cause of croup or improve airway patency.
D. Encouraging the child to drink adequate amounts of fluids may help prevent dehydration and thin the secretions, but it does not relieve the inflammation or narrowing of the airway.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is Choice B. Refer to the dermatologist for prescribed long-term therapy. Choice A rationale:
Omitting specific foods like chocolate, carbonated drinks, and fried foods from the diet is a common misconception about acne management. While a healthy diet can contribute to overall skin health, there is no direct evidence to support the notion that avoiding these foods alone will effectively treat acne. Acne is a complex skin condition influenced by various factors, including hormonal imbalances and genetics.
Choice B rationale:
Referring the client to a dermatologist for prescribed long-term therapy is the most appropriate recommendation for managing acne. Dermatologists are medical professionals specialized in skin conditions and can provide personalized treatment plans based on the client's specific type and severity of acne. They may prescribe topical or oral medications, such as retinoids, antibiotics, or hormonal therapy, to effectively manage acne.
Choice C rationale:
Expressing blackheads and using an exfoliating scrub is not a recommended approach for managing acne. Manual extraction of blackheads can lead to skin irritation, infection, and scarring. Exfoliating scrubs can also cause damage to the skin, especially if used too frequently or if the acne is inflamed.
Choice D rationale:
Washing the hair and skin daily with mild soap and warm water is a general hygiene recommendation and may help to keep the skin clean, but it is not a specific and effective treatment for acne. Acne requires targeted therapies to address its underlying causes and manage its symptoms.
Correct Answer is A
Explanation
This is the finding that the PN should report to the charge nurse because it indicates a possible complication of Guillain-Barre syndrome, which is autonomic dysfunction. This can affect the cardiac, respiratory, and gastrointestinal systems and cause life-threatening problems such as arrhythmias, hypotension, or respiratory failure. The PN should monitor the client's vital signs closely and report any abnormal changes.
B. Profuse diaphoresis is not a priority finding and may be related to other factors such as fever, anxiety, or medication side effects.
C. Lower leg weakness is an expected finding in Guillain-Barre syndrome and does not need to be reported unless it progresses rapidly or affects the respiratory muscles.
D. Full facial flushing is not a priority finding and may be related to other factors such as vasodilation, inflammation, or medication side effects.
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