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Calling the physician is not the first action because it would delay the immediate intervention of oxygen administration, which is critical for a patient with hypoxia. The physician should be notified after initiating oxygen therapy and assessing the patient's condition.

Placing the patient on 10 L/min oxygen per nasal cannula is not the first action because it is too high of a flow rate for a two-year-old patient, and it could cause oxygen toxicity or barotrauma. The appropriate oxygen delivery device and flow rate should be determined based on the patient's age, weight, and clinical status.

Assessing the patient is not the first action because it would also delay the immediate intervention of oxygen administration. The patient's pulse oximetry reading indicates severe hypoxia, which requires prompt treatment to prevent organ damage or death. The patient should be assessed after initiating oxygen therapy and monitoring vital signs.

Wheezes are high-pitched, musical sounds that occur during expiration. They are caused by the narrowing of the lower airway due to bronchoconstriction or mucus. Wheezes are more common in asthma than in croup.

Crackles are fine, crackling sounds that occur during inspiration. They are caused by the opening of collapsed or fluid-filled alveoli. Crackles are more common in pneumonia or heart failure than in croup.

Rhonchi are low-pitched, snoring sounds that occur during expiration. They are caused by the vibration of mucus in the large airways. Rhonchi are more common in bronchitis or cystic fibrosis than in croup.

Choice A: 0 - This would indicate that the child shows no signs of discomfort or pain. However, the nurse observed an occasional grimace and squirming, tense activity, which are signs of mild discomfort.

Choice C: 2 - A score of 2 would indicate more signs of discomfort or pain than observed. The child's legs were relaxed, there was no cry, and the child was consolable, which are all scored as 0.

Choice D: 3 - A score of 3 would suggest even more significant signs of discomfort or pain, which is not consistent with the nurse's observations.

APT stands for Acute Pain Team, which is a multidisciplinary team that provides pain management for patients. It is not a tool to assess pain.

Numeric is a pain scale that uses numbers from 0 to 10 to rate the intensity of pain. It is not suitable for a 4-year-old child who may not understand the concept of numbers or have difficulty expressing their pain level.

FLACC stands for Face, Legs, Activity, Cry, and Consolability. It is a pain scale that uses behavioral cues to assess pain in infants and young children who are unable to verbalize their pain. It is more appropriate for children under 3 years of age.

The child's current vital signs are not a reliable indicator of pain, as they may vary depending on the child's condition, medication, and stress level. Vital signs alone are not sufficient to assess pain in children.

The child becoming quiet when held and cuddled may indicate that the child is comforted by the nurse's presence and touch, not that the child is in pain. In fact, some children may become more vocal and restless when they are in pain.

The child having just returned from the recovery room does not necessarily mean that the child is in pain. The child may have received pain medication during or after the surgery, or the child may have a different pain threshold. The nurse should not assume that the child is in pain based on the procedure alone.

The child's current vital signs are consistent with vital signs over the past 4 hours. This does not indicate that the child is in pain, as the vital signs may be within normal range or stable.

The child becomes quiet when held and cuddled. This may indicate that the child is comforted by the nurse's presence and touch, not that the child is in pain.

The child has just returned from the recovery room. This may indicate that the child is still under the influence of anesthesia or sedation, not that the child is in pain.

This statement is false because children experience pain with procedures just as much as adults, if not more. Children may have more fear and anxiety associated with pain, which can amplify their perception of pain.

This statement is false because infants experience pain as much as older children and adults. Infants have a fully developed nervous system that can sense and respond to pain stimuli. Infants may also have more long-term effects of pain, such as altered pain sensitivity and behavioral problems.

This statement is false because children have a very low risk of becoming addicted to narcotics when they are used appropriately for pain management. Addiction is a psychological phenomenon that involves craving and compulsive use of a substance, which is rare in children who receive narcotics for pain relief.

This is not the best approach, as the parents may not be able to accurately rate the child's pain, especially if the child is too young or has communication difficulties.

This is not the best approach, as behavioral clues may not always reflect the intensity or quality of pain, and may be influenced by other factors such as fear, anxiety, or coping strategies.

This is not the best approach, as physiological measures may not always correlate with pain, and may be affected by other variables such as medication, stress, or illness.

A metered dose inhaler with spacer is a device that delivers medication to the lungs. It can help relieve or prevent asthma symptoms, but it does not measure how well the asthma is controlled.

Pulse oximetry is a device that measures the oxygen saturation of the blood. It can help detect hypoxia, which is a complication of asthma, but it does not measure how well the asthma is controlled.

Inhaled steroids are a type of medication that reduce inflammation in the airways. They can help prevent asthma attacks and improve lung function, but they do not measure how well the asthma is controlled.

This response is not appropriate because it does not address the mother's concern about antibiotics. It also implies that the nurse is making a medical decision for the child, which is beyond the scope of practice.

This response is not appropriate because it does not provide any reassurance or education to the mother. It also sounds dismissive of the child's condition and the mother's worry.

This response is not appropriate because it undermines the authority and judgment of the pediatrician. It also creates doubt and confusion in the mother's mind about the quality of care her child is receiving.

This response is not the priority action because dehydration is not an immediate threat to the child's life. The nurse should first rule out any signs of hemorrhage, which is a common complication of tonsillectomy.

This response is not the priority action because pain medication may mask the symptoms of bleeding, such as increased swallowing or restlessness. The nurse should first assess the child for any signs of hemorrhage, and then administer pain medication as needed.

This response is not the priority action because cherry popsicles may irritate the throat and cause bleeding. The nurse should first assess the child for any signs of hemorrhage, and then offer clear fluids or ice chips to the child.

This response is not correct because a faster heart rate does not necessarily imply respiratory compromise. A child's heart rate is normally faster than an adult's due to the smaller size and higher metabolic rate of the child.

This response is not correct because a greater body surface area does not directly affect the respiratory system. A child's body surface area is larger than an adult's in proportion to their body weight, which means they lose heat more easily and are more prone to hypothermia.

This response is not correct because the ability to verbalize is not a factor that contributes to respiratory compromise. However, the inability to verbalize may make it harder for the child to communicate their symptoms and needs, which may delay the recognition and treatment of respiratory problems.

This response is not correct because serum calcium is not related to CF. Serum calcium is a measure of the amount of calcium in the blood, which is influenced by factors such as diet, vitamin D, parathyroid hormone, and kidney function.

This response is not correct because bronchoscopy is not a diagnostic test for CF. Bronchoscopy is a procedure that involves inserting a flexible tube with a camera into the airways to examine the lungs and collect samples. Bronchoscopy may be used to treat complications of CF, such as mucus plugs or infections, but it is not essential for establishing the diagnosis.

This response is not correct because urine creatinine is not a diagnostic test for CF. Urine creatinine is a measure of the amount of creatinine, a waste product of muscle metabolism, in the urine. Urine creatinine reflects the kidney function and muscle mass, but it is not affected by CF.

Notifying the child's parents of his condition is important, but it is not the first action that the nurse should take. The nurse should prioritize the child's immediate needs and assess his respiratory status.

Educating the child to avoid triggers is a preventive measure that can help reduce the frequency and severity of asthma attacks, but it is not helpful in an acute situation. The nurse should focus on providing relief and monitoring the child's response.

Transporting the child to the emergency department may be necessary if the child does not respond to the initial interventions or if his condition worsens, but it is not the first action that the nurse should take. The nurse should first attempt to manage the child's symptoms in the office using the Asthma Action Plan.

Respiratory tract infection is not a correct answer because it is not a complication of examining the child's throat. It is a possible cause of epiglottitis, which is an inflammation of the epiglottis, the flap that covers the entrance to the trachea.

Sore throat is not a correct answer because it is not a complication of examining the child's throat. It is a symptom of epiglottitis, along with fever, difficulty swallowing, and drooling.

Inspiratory stridor is not a correct answer because it is not a complication of examining the child's throat. It is a sign of upper airway obstruction, which can occur in epiglottitis, but it is not caused by the tongue depressor.

Having a decongestant available to give the child when an attack occurs is not a correct answer because decongestants are not recommended for children under 6 years old. They can cause side effects such as increased heart rate, irritability, and insomnia.

Having the child sleep in a dry room is not a correct answer because dry air can worsen the inflammation and swelling of the airway. Moist air can help soothe the throat and reduce the coughing.

Giving the child an antibiotic at bedtime is not a correct answer because antibiotics are not effective for croup, which is usually caused by a virus. Antibiotics can also cause adverse reactions such as rash, diarrhea, and allergic reactions.

The child has a high fever is not a correct answer because fever is not a specific sign of croup. Fever can occur in many respiratory infections, such as bronchiolitis, pneumonia, or tonsillitis.

Wheezing is heard audibly is not a correct answer because wheezing is not a characteristic feature of croup. Wheezing is more common in asthma or bronchiolitis, which affect the lower airways.

It is bacterial in nature is not a correct answer because croup is usually caused by a virus, such as parainfluenza, adenovirus, or respiratory syncytial virus. Bacterial croup is rare and more severe, requiring hospitalization and antibiotics.

This is not the correct answer because making the girl lie down and rest quietly may worsen her respiratory distress and anxiety. The girl should be allowed to sit in a position of comfort and ease of breathing.

This is not the correct answer because a thorough neurological assessment is not the priority in this situation. The nurse should focus on the girl's airway, breathing, and circulation.

This is not the correct answer because auscultating the lungs and preparing for administering oxygen may not be sufficient to manage the girl's airway obstruction. The nurse should also have emergency equipment ready and call for assistance.

This is not the correct answer because Synagis® is a monoclonal antibody that is given as a prophylaxis to prevent severe RSV infection in high-risk infants. It is not effective as a treatment for RSV bronchiolitis.

This is not the correct answer because antiviral medication is not routinely recommended for RSV bronchiolitis, as it has not been shown to improve outcomes. Limiting fluids and giving antitussives may also be harmful, as they can cause dehydration and suppress the cough reflex.

This is not the correct answer because IV antibiotics are not indicated for RSV bronchiolitis, which is a viral infection. Antibiotics may increase the risk of antibiotic resistance and adverse effects.

This is not the correct answer because infant bones are not prone to fractures. They are more flexible and resilient than adult bones, and require more force to break.

This is not the correct answer because the focus should not be only on the injury, but also on how it occurred. The nurse should assess the mechanism of injury and the history of the child and the family for any signs of abuse or neglect.

This is not the correct answer because parents don't necessarily forget details when they are under stress. They may be anxious or emotional, but they should still be able to provide a consistent and coherent account of what happened.

Choice A: True - While it is true that a significant proportion of prisoners have experienced abuse in their childhood, the statement that over half of all violent offenders in prison were physically or sexually abused as children is not accurate according to available data¹²³.

A consistent growth pattern on the 25th percentile is not an indicator of child abuse. It means that the child is growing normally and is within the expected range for their age and gender.

A contusion on the child's leg is not necessarily an indicator of child abuse. It could be a result of accidental injury or normal play. However, the nurse should assess the location, size, shape, and color of the bruise, and compare it with the parents' explanation.

Fearful behavior when the nurse enters the room is not a specific indicator of child abuse. It could be a sign of anxiety, shyness, or discomfort in an unfamiliar setting. The nurse should try to establish rapport with the child and use developmentally appropriate communication techniques.

Emancipation is the legal process of granting a minor the rights and responsibilities of an adult. It is not related to the process of obtaining agreement from a child for medical treatment or research.

Informed consent is the process of obtaining permission from a competent individual for medical treatment or research, after providing them with adequate information about the risks and benefits. It is not applicable to children who are not legally capable of giving consent.

Confidentiality is the principle of protecting the privacy of personal information of patients or research participants. It is not the same as obtaining agreement from a child for medical treatment or research.

Fidelity is the principle of being faithful and loyal to one's commitments and obligations. It is not directly related to the situation, although the nurse may have a duty to respect the parent's wishes.

Equality is the principle of treating everyone fairly and impartially. It is not relevant to the situation, as there is no issue of discrimination or favoritism involved.

Justice is the principle of distributing benefits and burdens equitably and according to valid criteria. It is not pertinent to the situation, as there is no conflict of interest or allocation of resources involved.