The nurse performs an assessment of a child with pertussis (whooping cough). Which finding would the nurse identify as indicative of a potential complication?
A urinary output of 30 mL/hr
A white blood cell (WBC) count of 10.000 mm3 (10×109/L)
Decreased breath sounds in the lung bases
A weight gain
The Correct Answer is C
A. A urinary output of 30 mL/hr
Explanation: While decreased urinary output may indicate dehydration, it is not a specific finding related to pertussis. Dehydration can occur due to inadequate fluid intake or loss through vomiting or sweating.
B. A white blood cell (WBC) count of 10,000 mm3 (10×10^9/L)
Explanation: An elevated white blood cell count is a common finding in infections, including pertussis. It reflects the body's immune response to the infection. A WBC count of 10,000 mm3 is within the normal range, and while it indicates an inflammatory response, it does not specifically point to a complication.
C. Decreased breath sounds in the lung bases
Explanation:
Pertussis is a respiratory infection caused by the bacterium Bordetella pertussis. Complications can arise, including pneumonia. Decreased breath sounds in the lung bases may suggest the presence of pneumonia, which is a serious complication of pertussis. Pneumonia can lead to respiratory distress and requires prompt medical attention.
D. A weight gain
Explanation: Weight gain is not typically associated with pertussis. In fact, respiratory distress and difficulty feeding during coughing paroxysms can lead to weight loss in infants with pertussis. Weight gain may be indicative of other unrelated factors.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
A. Lateral deviation and rotation of each vertebra:
Correct Answer: Correct.
Explanation: Scoliosis involves a lateral (side-to-side) curvature of the spine and often includes some degree of vertebral rotation. Assessing for these deviations is crucial in diagnosing scoliosis.
B. Equal rib prominences:
Correct Answer: Incorrect.
Explanation: In scoliosis, the ribs may appear more prominent on one side due to the lateral curvature of the spine. Therefore, equal rib prominences would not typically be observed in scoliosis.
C. Unequal rib heights:
Correct Answer: Correct.
Explanation: Unequal heights of the ribs are commonly seen in scoliosis due to the asymmetrical nature of the spine's curvature.
D. Chest asymmetry:
Correct Answer: Correct.
Explanation: Asymmetry in the chest area, including differences in the shape or appearance of the chest, can be indicative of scoliosis, especially when associated with the spinal curvature.
E. Equal shoulder heights:
Correct Answer: Incorrect.
Explanation: In scoliosis, one shoulder might appear higher than the other due to the lateral curvature of the spine. Therefore, equal shoulder heights would not typically be observed in scoliosis.
F. Equal waist angles:
Correct Answer: Incorrect.
Explanation: Scoliosis often causes an asymmetrical appearance of the waistline due to the lateral curvature of the spine, resulting in unequal waist angles rather than equal ones.
Correct Answer is C
Explanation
A. That lethargy and vomiting are normal with mumps:
Incorrect: Lethargy and vomiting are not typical symptoms of mumps. These symptoms could indicate a separate issue that requires medical attention.
B. To continue to monitor the child:
Incorrect: Given the reported symptoms of lethargy and vomiting, a passive approach of continuing to monitor may delay necessary medical intervention. The child should be assessed promptly.
C. To bring the child to the clinic to be seen by the pediatrician:
Correct Answer: Lethargy and vomiting are not typical symptoms of uncomplicated mumps. These symptoms could be indicative of other issues, and it's important for the pediatrician to evaluate the child to determine the cause and provide appropriate care.
D. That there is nothing to be concerned about as long as there is no fever:
Incorrect: While fever is a common symptom of mumps, the absence of fever does not negate the need for further evaluation when there are concerning symptoms like lethargy and vomiting. The child should be seen by a healthcare provider to determine the cause of these symptoms.
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