The correct answer is choice A, “Your son has croup.”

Choice A rationale:

The symptoms described, including a barking cough, hoarseness, and inspiratory stridor, are classic signs of croup. Croup is a common respiratory condition in young children that leads to swelling of the larynx and trachea, causing the characteristic cough and stridor.

Choice B rationale:

While epiglottitis can present with respiratory distress, it is more commonly associated with high fever, severe sore throat, drooling, and difficulty swallowing, rather than a barking cough and stridor.

Choice C rationale:

Asthma typically presents with wheezing and difficulty exhaling, not the barking cough and inspiratory stridor seen in croup. Additionally, asthma is often associated with a history of allergies or atopic conditions, which are not mentioned in the scenario.

Choice D rationale:

Pneumonia usually presents with fever, cough producing phlegm, and crackles or wheezes on lung auscultation. The clear lungs on auscultation and the absence of productive cough make pneumonia less likely in this case.

In summary, the presentation of a barking cough, hoarseness, and inspiratory stridor in a young child who is in moderate respiratory distress with a recent onset of symptoms is most indicative of croup. This is supported by the age of the child and the clinical findings, which align with the typical presentation of croup.

Choice A rationale:

High fever is not a typical symptom of croup.

Croup is often caused by viral infections, and high fever is more commonly associated with bacterial infections.

This choice is incorrect.

Choice B rationale:

Inspiratory stridor is a classic symptom of croup and is caused by the narrowing of the larynx and trachea, leading to a high-pitched sound during inspiration.

This choice is correct.

Choice C rationale:

A barking cough is a distinctive symptom of croup and is caused by inflammation of the larynx and trachea.

This choice is correct.

Choice D rationale:

Wheezing is not a typical symptom of croup.

Wheezing is more commonly associated with conditions like asthma, where there is narrowing of the smaller airways (bronchioles).

This choice is incorrect.

Choice E rationale:

Respiratory distress, indicated by increased work of breathing, is a common symptom of croup.

It can manifest as the use of accessory muscles, intercostal retractions, and nasal flaring.

This choice is correct.

The nurse should assess the degree of airway obstruction to determine the severity of respiratory distress.

Choice A rationale:

Assessing the child's height and weight is important for overall health assessment but does not specifically determine the severity of respiratory distress in croup.

Respiratory distress is primarily evaluated by assessing airway patency, effort of breathing, and oxygenation.

Choice B rationale:

The child's vaccination history is crucial for preventing certain infectious diseases, but it does not directly assess the severity of respiratory distress in croup.

Croup is commonly caused by viral infections such as parainfluenza viruses.

Choice C rationale:

Assessing the degree of airway obstruction is essential in determining the severity of respiratory distress in croup.

Children with croup often present with stridor, a high-pitched sound heard during inspiration, indicating partial airway obstruction.

The severity of stridor, along with signs of increased work of breathing, provides valuable information about the child's respiratory status.

Choice D rationale:

The child's social activities are not directly related to the assessment of respiratory distress in croup.

While social history is important in a comprehensive nursing assessment, it does not provide specific information about the severity of airway obstruction in croup.

Nursing interventions for a child with croup include providing cool mist humidification, administering bronchodilators, and administering corticosteroids.

Choice A rationale:

Administering antibiotics is not a standard intervention for croup unless there is a secondary bacterial infection present.

Croup is typically caused by viral infections, so antiviral medications might be considered if the cause is identified as a specific virus.

However, antibiotics do not directly address the symptoms of croup.

Choice B rationale:

Providing cool mist humidification is appropriate for a child with croup.

Cool mist helps soothe the inflamed airways and can alleviate respiratory distress by reducing airway edema.

Moist air can make breathing easier for the child.

Choice C rationale:

Administering bronchodilators can be beneficial in the treatment of croup, especially if there is evidence of bronchoconstriction.

Bronchodilators help dilate the airways, making breathing easier for the child.

This intervention can be particularly useful if the child is experiencing wheezing in addition to stridor.

Choice D rationale:

Administering corticosteroids, such as dexamethasone, is a common and evidence-based intervention for croup.

Corticosteroids reduce airway inflammation and edema, leading to symptom improvement.

A single dose of oral corticosteroids is often sufficient to manage croup symptoms effectively.

Choice E rationale:

Encouraging the child to cough loudly is not a recommended intervention for croup.

Coughing forcefully may exacerbate airway irritation and inflammation, worsening the child's symptoms.

Instead, interventions should focus on reducing airway edema and providing respiratory support.

The nurse should assess the child's vital signs and listen to his lungs.

Choice A rationale:

Assessing vital signs, including heart rate, respiratory rate, oxygen saturation, and temperature, is essential in evaluating the child's overall condition and the severity of respiratory distress.

Listening to the child's lungs can help identify abnormal breath sounds, such as stridor or wheezing, which are common in croup.

This information guides further interventions and helps determine the appropriate level of care.

Choice B rationale:

While croup can cause respiratory distress, not every case requires an emergency room visit.

The severity of symptoms, including the child's ability to breathe and oxygenate, should guide the decision to seek emergency care.

In this scenario, assessing vital signs and lung sounds is the initial appropriate action.

Choice C rationale:

Croup is a treatable condition, and there are specific interventions, such as providing humidified air and corticosteroids, that can alleviate symptoms and prevent complications.

It is incorrect to tell the parent that there is nothing that can be done for croup.

Medical intervention can significantly improve the child's condition.

Choice D rationale:

Croup is primarily caused by viral infections, not bacterial infections.

Administering antibiotics without confirming a bacterial infection is inappropriate and contributes to antibiotic resistance.

Choice A rationale:

This statement does not indicate a complete understanding of croup.

Croup is not just a cold that affects the throat; it specifically involves inflammation of the upper airway.

Choice B rationale:

This statement acknowledges that croup can be serious but usually resolves on its own.

While this is true, it does not encompass the key symptoms and actions the parent should take if the child's condition worsens.

Choice C rationale:

This statement addresses general cold symptoms but does not specifically mention the characteristic symptoms of croup, such as barking cough, hoarseness, and stridor.

Choice D rationale:

This is The correct answer.

It shows an understanding of the symptoms of croup, particularly the mention of having trouble breathing, which is a sign of severe croup that requires medical attention.

Parents should seek emergency medical care if their child experiences difficulty breathing due to croup.

Providing this information demonstrates a comprehensive understanding of the condition.

Choice A rationale:

Administering oxygen therapy is essential in cases of severe croup where the child has difficulty breathing.

Oxygen therapy helps ensure adequate oxygenation, which is crucial in managing respiratory distress.

Choice B rationale:

Positioning the child upright facilitates breathing by allowing the airways to remain open and reducing airway obstruction.

This position helps alleviate symptoms like stridor and allows the child to breathe more comfortably.

Choice C rationale:

Providing humidified air helps loosen secretions and makes it easier for the child to breathe.

Humidification can reduce airway irritation and soothe the inflamed throat, providing relief from croup symptoms.

Choice D rationale:

This choice is incorrect because encouraging the child to drink plenty of fluids is generally good advice for any illness but is not specific to croup.

While it is essential to keep the child hydrated, it is not a direct nursing intervention for managing croup symptoms.

Choice E rationale:

Monitoring the child's respiratory status closely is crucial in assessing the effectiveness of the interventions and identifying any signs of respiratory distress.

Close monitoring allows nurses to make timely decisions and take appropriate actions to maintain the child's respiratory function.

Choice A rationale:

While giving the child plenty of water and juice is important for hydration, this statement does not address the specific management of croup symptoms.

Choice B rationale:

Running a hot shower and letting the child sit in the bathroom can create a steamy environment, but it is not the most effective way to provide humidified air.

A cool mist humidifier is a more controlled and efficient method for delivering humidified air to the child.

Choice C rationale:

This is The correct answer.

Using a cool mist humidifier in the child's bedroom is an appropriate way to provide humidified air, which can help ease breathing difficulties associated with croup.

Cool mist humidifiers add moisture to the air without heating it, making it easier for the child to breathe and reducing throat irritation.

Choice D rationale:

Giving the child a warm bath may provide some comfort but does not specifically address the need for humidified air, which is crucial in managing croup symptoms.

Providing humidified air helps soothe the inflamed airways and reduce respiratory distress associated with croup.

Choice A rationale:

Continuing to monitor the child's respiratory status may not be the best action in this situation, as the child's respiratory status is worsening and they are becoming increasingly agitated.

Immediate intervention is required to alleviate the child's distress.

Choice B rationale:

Administering oxygen therapy as needed is a supportive measure in respiratory distress situations, but in the case of severe croup with worsening respiratory status and agitation, nebulized epinephrine is the treatment of choice to reduce airway inflammation and improve breathing.

Choice C rationale:

Nebulized epinephrine is the primary treatment for severe croup as it helps reduce upper airway edema, relieve stridor, and improve respiratory distress.

It acts by causing vasoconstriction, which reduces swelling in the upper airway, making breathing easier for the child.

Therefore, preparing to administer nebulized epinephrine is the most appropriate action in this situation.

Choice D rationale:

Notifying the physician immediately is essential, but immediate intervention to improve the child's respiratory distress is also necessary.

Nebulized epinephrine should be administered promptly to alleviate the child's symptoms and prevent further deterioration.

Choice A rationale:

Placing the child on a ventilator might be necessary in severe cases of croup, but it should not be the first action taken.

In this scenario, the child has moderate croup, so less invasive interventions should be attempted first.

Choice B rationale:

Administering medication to help the child's cough and breathing is an appropriate first step in managing moderate croup.

Nebulized epinephrine or corticosteroids are commonly used to reduce airway inflammation and relieve respiratory distress in croup.

This intervention can be effective in improving the child's symptoms and overall condition.

Choice C rationale:

Transferring the child to the ICU for closer monitoring is not immediately necessary in this case of moderate croup.

Such a step might be considered if the child's condition worsens despite initial interventions or if there are signs of severe respiratory distress.

Choice D rationale:

Discharging the child home without appropriate treatment and monitoring would be unsafe, given the child's symptoms and oxygen saturation level.

Immediate intervention and observation are required to ensure the child's respiratory status improves.

Choice A rationale:

Croup is indeed a common viral infection of the upper respiratory tract that causes inflammation of the larynx.

This statement is accurate and important for the parent to understand the nature of the illness.

Choice B rationale:

Croup is most common in children under the age of 5, not just under the age of 3.

However, this statement is not entirely accurate, as older children can also be affected by croup.

It is essential to provide correct information to the parent.

Choice C rationale:

The symptoms of croup often worsen at night due to the natural narrowing of the airways during sleep, making breathing more difficult.

Therefore, this statement is correct and relevant to include in the teaching.

Choice D rationale:

The classic croup cough is indeed described as a barking cough, which results from the inflammation of the larynx and trachea.

This description helps the parent recognize a distinctive symptom of croup.

Including this information in the teaching is appropriate.

Choice E rationale:

Croup is primarily managed with supportive care, such as humidified air and nebulized medications.

Over-the-counter cough syrup and expectorants are not typically recommended for treating croup in children.

This statement is incorrect and should not be included in the teaching.

Choice A rationale:

An oxygen saturation level of 95% is within the normal range (normal range is typically 95-100%).

While it is essential to monitor oxygen saturation, this value does not indicate worsening of the child's condition.

Choice B rationale:

A respiratory rate of 30 breaths per minute is above the normal range for a child and can indicate respiratory distress.

An increased respiratory rate is a concerning sign, suggesting the child is having difficulty breathing.

This finding indicates the child's condition is worsening and requires prompt attention.

Choice C rationale:

Mild retractions suggest that the child is working harder to breathe but may not necessarily indicate a severe worsening of the condition.

Retractions are a sign of increased respiratory effort but may vary in severity.

Choice D rationale:

A child with croup experiencing severe respiratory distress may not be able to speak in complete sentences due to the difficulty in breathing.

However, the ability to speak in complete sentences alone may not be a definitive indicator of worsening.

Monitoring the respiratory rate and effort is crucial in assessing the child's condition accurately.

Choice A rationale:

There is no vaccine to prevent croup, but practicing good hand hygiene and avoiding contact with sick people can help reduce the child's risk of getting croup.

Croup is mainly caused by viral infections, so minimizing exposure to viruses is essential in prevention.

Choice B rationale:

Giving a daily dose of vitamin C is not a proven method for preventing croup.

While vitamin C is essential for overall health, it does not specifically prevent croup.

Providing accurate and evidence-based information is crucial in parental education.

Choice C rationale:

Keeping the child's bedroom cool and humid may provide comfort during the illness, but it is not a proven method for preventing croup.

This statement does not contribute significantly to preventive measures against croup.

Choice D rationale:

Using a humidifier in the home can help maintain adequate humidity levels, which may reduce the risk of croup, especially during dry seasons.

Proper humidity can prevent irritation of the upper respiratory tract and decrease the likelihood of developing croup.

Including this information in the teaching is appropriate and beneficial for the parent to know.

Choice A rationale:

Tonsillitis is not always caused by bacterial infections.

It can also be caused by viral infections.

Choice B rationale:

Tonsillitis is not only caused by viral infections.

Bacterial infections can also lead to tonsillitis.

Choice C rationale:

Tonsillitis can be caused by either viral infections such as adenovirus, rhinovirus, or Epstein-Barr virus, or bacterial infections, particularly Streptococcus pyogenes.

This is the most accurate statement.

Streptococcus pyogenes is a common bacterial cause of tonsillitis, and viral infections can also lead to this condition.

Choice D rationale:

Tonsillitis is not usually caused by allergies.

While allergies can cause throat discomfort, they are not a common cause of tonsillitis.

Choice A rationale:

Enlarged tonsils might contribute to recurrent tonsillitis, but it is not the primary cause.

Choice B rationale:

Dust and irritants can irritate the throat, but they are not the main reason for recurring tonsillitis.

Choice C rationale:

Your child’s immune system might be deficient, making them more susceptible to infections.

This response is appropriate because a weakened immune system can make a child more prone to recurrent infections, including tonsillitis.

Choice D rationale:

Improper handwashing can lead to various infections, but it is not specifically linked to tonsillitis.

Choice A rationale:

The child has been having difficulty swallowing.

Difficulty swallowing is a common symptom of tonsillitis.

Inflamed tonsils can make swallowing painful and difficult.

Choice B rationale:

The child has been experiencing ear pain.

While ear pain can be associated with throat infections, it is not a direct symptom of tonsillitis.

Choice C rationale:

The child has a rash on their arms and legs.

A rash is not a typical symptom of tonsillitis.

It could indicate other conditions such as an allergic reaction or viral illness.

Choice D rationale:

The child’s tonsils appear red and swollen.

Red and swollen tonsils are characteristic signs of tonsillitis.

Inflammation of the tonsils is a key indicator of the condition.

Choice E rationale:

The child has been experiencing frequent nosebleeds.

Nosebleeds are not typically associated with tonsillitis.

They could be due to other factors such as dry air or nasal irritation.

Choice A rationale:

Bacterial tonsillitis is caused by the colonization of bacteria on the tonsils, triggering an immune response.

When bacteria, often Streptococcus species, invade the tonsils, the body's immune system recognizes them as foreign invaders.

This recognition prompts an immune response, leading to inflammation and swelling of the tonsils.

The immune system releases white blood cells and other substances to fight the infection, causing the characteristic symptoms of tonsillitis, such as sore throat, difficulty swallowing, and fever.

This process is a localized immune response specific to the tonsils and their surrounding tissues.

Choice B rationale:

This choice is incorrect because bacteria do not invade the tonsils directly and immediately cause inflammation and swelling.

The immune response is triggered upon recognition of the bacteria, leading to the inflammation and swelling of the tonsils.

Choice C rationale:

This choice is incorrect because bacterial tonsillitis is not caused by an allergic reaction in the tonsils.

It is primarily a result of a bacterial infection, not an allergic response.

Choice D rationale:

This choice is incorrect because bacterial tonsillitis is a localized infection in the tonsils and does not cause a systemic infection that indirectly leads to tonsillitis.

The infection remains localized in the throat area, causing symptoms specific to the tonsils and nearby lymph nodes.

Choice A rationale:

When assessing a client with suspected tonsillitis, it is essential to consider whether the client has been exposed to viral or bacterial infections recently.

Tonsillitis can be caused by both viral and bacterial infections, with streptococcal bacteria being a common culprit.

Understanding the type of infection helps healthcare providers determine the appropriate treatment, such as antibiotics for bacterial infections.

Recent exposure to infected individuals or environments increases the likelihood of a contagious infection.

Choice B rationale:

This choice is incorrect because while a balanced diet is crucial for overall health, it is not a direct factor in the etiology of tonsillitis.

Tonsillitis is primarily caused by infections, either viral or bacterial, and is not related to dietary habits.

Choice C rationale:

This choice is incorrect because exposure to cold temperatures is not a direct cause of tonsillitis.

Tonsillitis is caused by infections and is not related to environmental factors like cold weather.

However, cold weather can weaken the immune system, making individuals more susceptible to infections.

Choice D rationale:

This choice is incorrect because recent injuries to the throat area can cause throat pain and discomfort but are not a common cause of tonsillitis.

Tonsillitis is predominantly caused by infections, and injuries play a minor role in its etiology.

Choice A rationale:

Encouraging the child to drink plenty of fluids is a suitable response by the mother.

Staying hydrated is essential to prevent dehydration, especially when the child has difficulty swallowing due to swollen tonsils.

Adequate fluid intake can also soothe the throat and help in the recovery process.

Choice B rationale:

Providing warm soup to soothe the throat is a suitable response.

Warm, soothing liquids can help alleviate throat discomfort and make swallowing easier.

It is a common home remedy for managing sore throat symptoms.

Choice C rationale:

This choice is correct because encouraging the child to cough to clear the throat is not appropriate.

Coughing can irritate the already inflamed tonsils and worsen the sore throat.

Instead, the child should be advised to avoid coughing forcefully, which can aggravate the pain.

Choice D rationale:

Giving the child over-the-counter pain medication as directed is a suitable response.

Over-the-counter pain relievers like acetaminophen or ibuprofen can help reduce pain and fever associated with tonsillitis.

However, it's important to use these medications as directed by a healthcare professional or following the recommended dosage instructions, especially in children.

Choice A rationale:

The client's symptoms, including sore throat, difficulty swallowing, fever, red and swollen tonsils with white patches, enlarged lymph nodes, bad breath, headache, and abdominal pain, indicate possible tonsillitis, which is often caused by a bacterial infection.

Rest and increased fluid intake are essential components of the care plan for tonsillitis.

Adequate rest helps the body fight the infection, and increased fluid intake helps prevent dehydration, especially if swallowing is painful.

This choice demonstrates the client's understanding of self-care measures to promote recovery.

Choice B rationale:

Continuing to smoke can worsen the irritation of the throat and prolong the healing process.

Smoking irritates the mucous membranes, making it difficult for the throat to heal.

It can also exacerbate the symptoms and delay recovery.

Choice C rationale:

Tonsillitis caused by bacteria often requires antibiotics to clear the infection completely.

Taking antibiotics only when in pain might lead to incomplete eradication of the bacteria, resulting in a recurrence of the infection or complications.

It is essential to take the full course of antibiotics as prescribed by the healthcare provider.

Choice D rationale:

Going to work when experiencing symptoms of tonsillitis not only jeopardizes the client's health but also puts coworkers at risk of contracting the infection.

Resting at home and avoiding contact with others can prevent the spread of the illness.

Choice A rationale:

Assessing for drooling is important because severe tonsillitis can cause difficulty swallowing, leading to excessive drooling, especially in children.

Drooling indicates difficulty managing oral secretions and can be a sign of airway obstruction, necessitating immediate medical attention.

Choice B rationale:

Assessing for an earache is crucial because the infection from the tonsils can spread to the nearby ear structures, causing ear pain.

Earache in conjunction with other symptoms can indicate the spread of the infection and may require additional medical evaluation and treatment.

Choice C rationale:

Assessing for neck stiffness is important because it can be a sign of meningitis, a serious complication of some bacterial infections, including streptococcal bacteria that can cause tonsillitis.

Neck stiffness, along with other symptoms, can indicate the involvement of the central nervous system and requires urgent medical attention.

Choice D rationale:

Assessing for increased energy levels is not relevant to tonsillitis.

In fact, individuals with tonsillitis often experience fatigue due to the body's immune response to the infection.

Increased energy levels would not be a typical symptom of this condition.

Choice E rationale:

Assessing for vomiting is not a common symptom of tonsillitis.

While individuals with severe throat pain might have difficulty swallowing, leading to decreased oral intake, vomiting is not a direct symptom of tonsillitis.

Vomiting could indicate other underlying issues that need further assessment but is not specifically related to tonsillitis.

Choice A rationale:

This statement uses fear as a tactic to encourage the child to drink fluids, which is not a supportive or therapeutic approach.

It may create anxiety and resistance in the child, making them less likely to cooperate.

Choice B rationale:

This statement provides a positive and encouraging approach by explaining the benefits of drinking fluids.

It educates the child about the importance of hydration in feeling better faster, which can motivate them to cooperate with the nurse's recommendations.

Choice C rationale:

Threatening the child with an injection may create fear and distress, potentially worsening the child's refusal to drink fluids.

This approach is not conducive to building trust and cooperation with the child.

Choice D rationale:

Using threats related to discharge or privileges may cause stress and anxiety in the child.

It is important to maintain a supportive and reassuring approach to promote cooperation and comfort in the child.

Choice A rationale:

Stopping antibiotics once feeling better can lead to incomplete eradication of the infection, allowing remaining bacteria to develop resistance to the antibiotic.

It is essential to complete the full course of antibiotics to ensure complete resolution of the infection.

Choice B rationale:

Finishing all the antibiotics, even if symptoms improve, is crucial to prevent the development of antibiotic-resistant strains of bacteria.

Incomplete courses of antibiotics can lead to treatment failure and potential complications.

Choice C rationale:

While it is important to monitor for and report any side effects of antibiotics, stopping the medication immediately without consulting a healthcare provider can compromise the effectiveness of the treatment.

The nurse should instruct the client to report any adverse reactions for proper evaluation and management.

Choice D rationale:

Sharing antibiotics with others is dangerous and highly discouraged.

Each person's condition is unique, and taking antibiotics without proper diagnosis and prescription can lead to inappropriate use, antibiotic resistance, and potential harm to individuals with allergies or other medical conditions.

Choice A rationale: Encouraging the child to participate in strenuous physical activities is not appropriate for a child with tonsillitis. Strenuous activities can exacerbate symptoms and delay recovery. Rest is important to help the child’s body fight the infection and recover more quickly. Therefore, it is not recommended to promote strenuous physical activities during illness.

Choice B rationale: Providing pain relief measures, such as acetaminophen or ibuprofen, as prescribed, is important for managing the symptoms of tonsillitis. These medications can help reduce pain and fever, making the child more comfortable. Proper pain management is essential to ensure the child's comfort and facilitate recovery.

Choice C rationale: Offering cool or warm liquids and soft foods can help soothe a sore throat, which is a common symptom of tonsillitis. Cool liquids can help reduce throat swelling and irritation, while warm liquids can provide comfort. Soft foods are easier to swallow and less likely to irritate the inflamed throat. This dietary modification can help manage symptoms and promote recovery.

Choice D rationale: Educating the child and family about the importance of completing prescribed antibiotic therapy is crucial in the treatment of bacterial tonsillitis. Completing the full course of antibiotics ensures that the infection is fully eradicated and helps prevent the development of antibiotic-resistant bacteria. This education can lead to better adherence to the treatment regimen and more effective management of the condition.

Choice E rationale: Discouraging rest and promoting active play is not suitable for a child with tonsillitis. Rest is essential for recovery as it helps the body conserve energy to fight the infection. Active play can increase discomfort and fatigue, delaying recovery. Therefore, encouraging rest and avoiding strenuous activities is important for managing tonsillitis effectively.

Choice A rationale:

Having at least one episode of tonsillitis might not be a sufficient indication for a tonsillectomy.

Tonsillectomy is typically considered for recurrent tonsillitis, not just a single episode.

Choice B rationale:

Tonsillectomy is considered when the child's tonsillitis does not respond to antibiotic therapy and becomes recurrent.

Recurrent tonsillitis can significantly impact a child's quality of life and may necessitate surgical intervention to prevent frequent infections and complications.

Choice C rationale:

Mild throat discomfort alone is not a strong indication for tonsillectomy.

Tonsillectomy is usually reserved for cases of recurrent tonsillitis that do not respond to conservative treatments.

Choice D rationale:

The parents' anxiety about their child's condition is not a direct indication for tonsillectomy.

The decision for surgery should be based on the child's medical condition and the medical necessity of the procedure.

Choice A rationale:

Erythromycin is an antibiotic that does not primarily target inflammation and swelling in the tonsils.

Its mechanism of action involves inhibiting protein synthesis in bacteria, thereby preventing the growth and spread of the bacterial infection causing tonsillitis.

Choice B rationale:

Erythromycin is used to treat bacterial infections by inhibiting protein synthesis in bacteria.

It is effective against a wide range of bacterial strains and can be prescribed for various infections, including tonsillitis, caused by susceptible bacteria.

Choice C rationale:

Erythromycin does not provide symptomatic relief from throat pain and discomfort directly.

While it addresses the underlying bacterial infection, it does not have analgesic properties to relieve pain.

Pain relief measures, such as acetaminophen or ibuprofen, are typically prescribed for managing throat pain associated with tonsillitis.

Choice D rationale:

Erythromycin does not prevent dehydration by encouraging fluid intake.

While staying hydrated is essential during illness, the role of erythromycin is to target the bacterial infection, not to promote fluid intake.

Choice A rationale:

This statement is incorrect.

RSV is most common in winter and early spring, not summer and fall.

Stating this misinformation would not effectively educate the parents about RSV prevention during the high-risk months.

Choice B rationale:

This is The correct answer.

RSV does occur in yearly outbreaks, especially in winter and early spring.

By emphasizing this, the nurse educates parents about the specific periods when they should take extra precautions to prevent RSV transmission.

Choice C rationale:

This statement is incorrect.

RSV is indeed seasonal, with higher incidence during the winter and early spring months.

Denying its seasonality would provide inaccurate information to the parents.

Choice D rationale:

This statement is incorrect.

RSV primarily affects infants and young children, not adults.

Providing this misinformation would not help parents understand the risks associated with RSV for their children.

Choice A rationale:

This is The correct answer.

RSV can survive on hard surfaces for several days and on hands for several hours.

Providing this information addresses the client's concern about the virus's survivability on surfaces.

Choice B rationale:

This statement is incorrect.

RSV can survive on hard surfaces for a longer duration than just several hours.

Providing this incorrect information could lead to misunderstandings about RSV transmission.

Choice C rationale:

This statement is incorrect.

RSV can survive on surfaces, so stating that it cannot survive outside of the body would be inaccurate and misleading.

Choice D rationale:

This statement is incorrect.

RSV can be transmitted not only through direct contact with an infected person but also through contact with contaminated surfaces and respiratory droplets.

Choice A rationale:

This statement is incorrect.

A history of recurrent pneumonia is not a specific indicator of RSV infection.

RSV primarily affects the respiratory system, causing symptoms such as cough, wheezing, and difficulty breathing.

Choice B rationale:

This is a correct answer.

RSV symptoms typically appear 2 to 5 days after exposure.

Including this option helps identify the duration of symptoms, which is relevant to diagnosing RSV.

Choice C rationale:

This is a correct answer.

RSV commonly presents with symptoms like high fever and severe cough.

Recognizing these symptoms can help healthcare providers consider RSV as a possible diagnosis.

Choice D rationale:

This is a correct answer.

RSV can lead to bronchiolitis, which is inflammation of the small airways in the lungs.

Diagnosing a child with bronchiolitis can raise suspicion of RSV infection.

Choice E rationale:

This statement is incorrect.

A history of bacterial infections is not specific to RSV and does not provide relevant information for identifying RSV infection in this context.

Choice A rationale:

RSV (Respiratory Syncytial Virus) primarily affects young children and infants, making them more vulnerable to severe complications.

Adults can also contract the virus, but it is most common and dangerous in children under one year old.

Therefore, stating that RSV is most common in adults is incorrect.

Choice B rationale:

RSV is most common in children under one year old, so your grandchildren could be at risk.

This statement is correct.

RSV is highly contagious and spreads through respiratory droplets.

Infants and young children are more prone to severe infections due to their underdeveloped immune systems.

Hence, the nurse should educate the client that their grandchildren, especially those under one year old, are at risk of contracting RSV.

Choice C rationale:

RSV does affect individuals with compromised immune systems, but it is not limited to them.

Children, especially those under one year old, are also highly susceptible to RSV infections.

Therefore, this statement is not comprehensive and accurate.

Choice D rationale:

RSV can be transmitted from person to person through respiratory secretions.

It is highly contagious, especially in crowded places like daycare centers and hospitals.

This statement is incorrect, as RSV transmission is well-documented.

Choice A rationale:

RSV infects the squamous epithelial cells of your bronchioles, alveoli, and nasal passages.

This statement is accurate.

RSV primarily targets the respiratory tract, infecting the cells lining the bronchioles, alveoli, and nasal passages.

This infection can lead to symptoms ranging from mild cold-like symptoms to severe respiratory distress, particularly in young children and individuals with weakened immune systems.

Choice B rationale:

RSV does not cause the immune system to attack the body's own cells.

It primarily targets the respiratory system, leading to respiratory symptoms.

Autoimmune responses are not associated with RSV infections.

Choice C rationale:

RSV does not lead to an overproduction of red blood cells.

This statement is incorrect and not related to the pathophysiology of RSV infections.

Choice D rationale:

RSV does not cause the body to stop producing white blood cells.

White blood cells play a crucial role in the immune response, and stopping their production would severely compromise the body's ability to fight infections.

RSV primarily affects the respiratory system and does not directly impact white blood cell production.

Choice A rationale:

Your child may start to experience difficulty breathing.

This statement is accurate and crucial for the mother to be aware of.

RSV infections can progress to bronchiolitis or pneumonia, leading to more severe respiratory distress.

Difficulty breathing is a common symptom in these advanced stages of the infection, indicating the need for immediate medical attention.

Choice B rationale:

While a decreased appetite is a symptom mentioned in the scenario, it does not reflect the potential progression of RSV infection.

The focus should be on respiratory symptoms, which can indicate worsening conditions.

Choice C rationale:

Drowsiness is not a typical symptom of RSV progression.

Respiratory distress, such as difficulty breathing, is a more concerning sign and requires prompt medical evaluation.

Choice D rationale:

Developing a high fever is a general symptom of various infections, including RSV.

While fever is a concern, the scenario specifically mentions symptoms related to the respiratory system, making difficulty breathing a more relevant and specific warning sign for the mother to be aware of.

Choice A rationale:

The nurse should reassure the client by stating, “We will monitor your child closely for any signs of respiratory distress.”.

This is the appropriate response because close monitoring is crucial in children with RSV infection, especially those younger than age 3.

Respiratory distress can rapidly progress in this age group, and early detection is essential for timely intervention.

Monitoring the child's respiratory rate, oxygen saturation, and other respiratory symptoms allows healthcare providers to assess the severity of the condition and provide appropriate interventions promptly.

Choice B rationale:

While ensuring rest and fluids is generally good advice for managing various illnesses, it does not specifically address the client’s concerns about the potential complications of RSV infection, such as bronchiolitis or pneumonia leading to respiratory distress.

Choice C rationale:

Administering medication to reduce fever is not the most pertinent information in this scenario.

The primary concern for the client is the progression of RSV infection to severe respiratory distress, not fever reduction.

Choice D rationale:

Providing a special diet to improve appetite does not address the client’s concerns about the respiratory complications associated with RSV infection.

Respiratory distress is the main worry in this situation, and dietary changes are not the appropriate focus.

Choice A rationale: The child’s respiratory rate of 35 breaths per minute is slightly elevated but not uncommon for a 3-year-old with a respiratory infection like RSV. Given the child's oxygen saturation is 96%, which is within normal range, it is appropriate to continue monitoring the respiratory rate. Monitoring ensures any changes in the child’s condition can be promptly addressed without unnecessary interventions.

Choice B rationale: Administering supplemental oxygen is not necessary in this case because the child’s oxygen saturation is 96%, which is within the normal range (95-100%). Providing supplemental oxygen without clinical indication can cause potential harm and is not warranted when oxygen levels are adequate.

Choice C rationale: Reassessing the child’s oxygen saturation in one hour is a prudent action. This allows the nurse to ensure that the child’s oxygen levels remain stable and to detect any potential decline in respiratory function. It provides an ongoing assessment to ensure the child's condition does not worsen.

Choice D rationale: The pH value of 7.38 is within the normal range (7.35-7.45), indicating that the child is not experiencing acid-base imbalance. There is no immediate need to notify the healthcare provider about the pH value alone, as it does not suggest any critical condition requiring urgent intervention.

Choice E rationale: Preparing for immediate intubation due to elevated PaCO2 is not warranted. The child’s PaCO2 is 40, which is within the normal range for carbon dioxide levels (35-45 mmHg). Intubation is a severe intervention reserved for cases of respiratory failure, which is not indicated by the presented lab results.

Choice A rationale:

Administering bronchodilators as prescribed is appropriate for managing severe respiratory distress and wheezing in children with RSV infection.

Bronchodilators help dilate the airways, making it easier for the child to breathe.

This intervention addresses one of the specific symptoms mentioned in the scenario.

Choice B rationale:

Encouraging fluid intake is important to prevent dehydration, especially in children with respiratory infections.

It helps maintain hydration status, which is essential for overall health.

While important, this choice alone does not address the severe respiratory distress symptoms mentioned in the scenario.

Choice C rationale:

Monitoring oxygen saturation levels is crucial in children with RSV infection, especially when they exhibit symptoms of severe respiratory distress such as wheezing, retractions, nasal flaring, tachypnea, and cyanosis.

Monitoring oxygen saturation helps assess the child's oxygenation status and guides interventions such as oxygen therapy.

Choice D rationale:

The correct answer is choice D, “All of these.”.

This is because all the interventions mentioned in choices A, B, and C are appropriate and necessary for managing severe respiratory distress in a toddler with RSV infection.

Administering bronchodilators addresses airway constriction and wheezing, encouraging fluid intake prevents dehydration, and monitoring oxygen saturation levels ensures appropriate oxygenation, allowing comprehensive care for the child’s condition.

Choice A rationale:

The nurse should educate the client about the expected course of RSV infection in infants.

RSV (Respiratory Syncytial Virus) infection can lead to complications such as bronchiolitis or pneumonia, especially in children under the age of 3.

Symptoms like wheezing and tachypnea are indicative of respiratory distress.

Educating the client about the expected duration of the symptoms is crucial.

The client needs to understand that the baby's symptoms may last for about 10 days, and this is a common timeframe for the resolution of RSV infection in infants.

This information helps manage the client's expectations and reduces anxiety.

Choice B rationale:

While fever can be a sign of infection, it is not the most pertinent symptom to monitor in this case.

The primary concern is the respiratory distress caused by bronchiolitis or pneumonia.

While fever might indicate worsening infection, it is not the most relevant information in this context.

Choice C rationale:

Over-the-counter cold medicine is generally not recommended for infants and young children due to the risk of side effects.

Moreover, these medications may not be effective in managing the specific symptoms caused by RSV infection.

Advising the client to administer such medication could be harmful and is not an appropriate response.

Choice D rationale:

While it is essential to prevent the spread of RSV infection, especially among siblings, this choice does not address the client's understanding of the infant's condition.

The primary concern here is the client's grasp of the infant's symptoms and the expected course of the illness, which is best addressed by choice A.

Choice A rationale:

Keeping the child calm and comfortable is generally advisable, but in the context of RSV infection, maintaining a patent airway is crucial.

While comfort measures are essential, this choice does not directly address the mother's query regarding improving the child's breathing.

Choice B rationale:

This is The correct answer because suctioning the child's nose and mouth as needed helps in removing secretions, thus maintaining a clear airway.

RSV infection often leads to increased mucus production, which can obstruct the airways, making it difficult for the child to breathe.

By suctioning secretions, the mother can help her child breathe more comfortably, which is essential in managing RSV infection.

Choice C rationale:

Over-the-counter cold medicine is generally not recommended for infants and young children due to the risk of adverse effects.

Additionally, these medications may not specifically address the underlying cause of respiratory distress in RSV infection.

Choice D rationale:

Avoiding feeding the child until their breathing improves is not appropriate advice.

Nutrition is essential, especially for infants, and withholding feeding could lead to dehydration and other complications.

It is important to maintain adequate nutrition while managing the respiratory distress caused by RSV infection.

Choice A rationale:

This is The correct answer because it addresses the client's concern about dehydration.

Infants and young children with RSV infection are at risk of dehydration due to increased respiratory effort, fever, and decreased oral intake.

Encouraging oral fluids or providing intravenous fluids as prescribed helps prevent dehydration, ensuring the child remains hydrated during the illness.

Choice B rationale:

While adequate fluid intake is essential, stating a specific quantity like 8 glasses of water a day is not appropriate for infants and young children.

The fluid requirements vary based on the child's age, weight, and overall health condition.

Providing a specific quantity without proper assessment can be misleading and may not meet the child's individual needs.

Choice C rationale:

Limiting the child's fluid intake to prevent overhydration is not the primary concern in this context.

Dehydration due to increased respiratory effort and decreased oral intake is a more significant concern.

Adequate hydration is crucial in preventing complications associated with dehydration.

Choice D rationale:

Restricting the child to clear liquids only is not appropriate, especially in the context of RSV infection.

While clear liquids are essential, they may not provide adequate nutrition.

Maintaining appropriate oral intake, which includes a variety of fluids and, if possible, nutritionally balanced foods, is important for the child's overall well-being during the illness.

Choice A rationale:

Isolating the child from other children or adults with respiratory infections is crucial in preventing the spread of Respiratory Syncytial Virus (RSV).

RSV is highly contagious and spreads through respiratory droplets.

By isolating the infected child, the nurse helps prevent the transmission of the virus to others.

Choice B rationale:

Using contact precautions such as gown and gloves when caring for the child is essential to prevent the spread of RSV.

Direct contact with respiratory secretions can easily lead to transmission.

Wearing protective gear like gowns and gloves creates a barrier, reducing the risk of contamination and spread.

Choice C rationale:

Encouraging frequent hand hygiene is a fundamental preventive measure.

RSV can survive on surfaces for several hours, so regular handwashing with soap and water for at least 20 seconds can help eliminate the virus from hands, reducing the risk of infection.

Choice E rationale:

Avoiding exposure to tobacco smoke is important because smoke irritates the respiratory tract, making individuals more susceptible to respiratory infections like RSV.

Secondhand smoke can also worsen symptoms in infected individuals and increase the severity of the illness.

Choice D rationale:

Allowing siblings to share toys and utensils with the infected child is not recommended.

RSV spreads through respiratory droplets and direct contact with contaminated surfaces.

Sharing toys and utensils can facilitate the transmission of the virus to other children, increasing the risk of infection.

Choice B rationale:

Offering frequent small feedings of breast milk or formula to maintain nutrition is an appropriate response.

Infants with RSV may experience decreased appetite and difficulty feeding due to respiratory distress.

Providing small, frequent feedings ensures that the infant receives adequate nutrition and hydration despite reduced intake during each feeding session.

Choice A rationale:

Giving the baby aspirin if they develop a fever is not recommended.

Aspirin use in children with viral infections like RSV has been associated with Reye's syndrome, a severe and potentially fatal condition.

Acetaminophen or ibuprofen, if appropriate for the child's age, can be used to manage fever and discomfort.

Choice C rationale:

Keeping the baby in a flat position to promote comfort is not advisable.

Elevating the head of the crib or bassinet slightly can help improve breathing and reduce nasal congestion in infants with respiratory infections, promoting better comfort and easier breathing.

Choice D rationale:

Stopping all feedings if the baby seems to be having trouble breathing is not The correct approach.

Adequate nutrition is crucial for the infant's overall health and recovery.

Instead, the caregiver should seek medical advice if the baby experiences significant difficulty breathing or feeding.

Adjustments in feeding techniques or temporary alternative feeding methods may be recommended under medical supervision.

Choice A rationale:

Epiglottitis is most commonly caused by bacterial infections, specifically Haemophilus influenzae type b (Hib) bacteria.

This bacterium can cause inflammation and swelling of the epiglottis, leading to airway obstruction.

Viral infections are not the primary cause of epiglottitis in children.

Choice B rationale:

Epiglottitis primarily affects children, not adolescents and adults.

The peak incidence occurs in children between the ages of 2 and 6 years.

Choice C rationale:

The child adopting a tripod position, leaning forward with outstretched arms, is a classic sign of epiglottitis.

This position helps maximize airway patency and ease breathing.

It is a protective mechanism that children instinctively assume to maintain their airway.

Choice D rationale:

Epiglottitis does not typically result in a loud, high-pitched cry.

The child with epiglottitis is usually quiet and prefers to sit still in a tripod position to maintain airway patency.

Choice A rationale:

Epiglottitis does not cause the epiglottis to shrink and recede into the throat.

Instead, it leads to inflammation and swelling of the epiglottis, causing airway obstruction.

Choice B rationale:

The inflammation in epiglottitis does not primarily affect the vocal cords.

It specifically affects the epiglottis, a flap-like structure located at the base of the tongue, which covers the trachea during swallowing to prevent food or liquid from entering the windpipe.

Choice C rationale:

Epiglottitis leads to increased airway resistance and respiratory distress due to the swelling and obstruction of the airway.

This can result in difficulty swallowing, drooling, and a muffled voice, as seen in the client's symptoms described in the question.

Choice D rationale:

The swelling in epiglottitis is not limited to the vocal cord area.

It involves the epiglottis, which can obstruct the airway and cause respiratory distress.

Choice A rationale:

Haemophilus influenzae type b (Hib) infection is a significant risk factor for epiglottitis in children.

Hib vaccination has significantly reduced the incidence of epiglottitis caused by this bacterium.

Choice B rationale:

Trauma to the throat or neck is not a common risk factor for epiglottitis.

The primary cause is bacterial infection, especially by Hib bacteria.

Choice C rationale:

Thermal injury from hot liquids can lead to thermal epiglottitis, a rare condition caused by the inhalation of hot steam or liquid, resulting in inflammation and swelling of the epiglottis.

Choice D rationale:

Seasonal factors are not a direct risk factor for epiglottitis.

The condition is primarily caused by bacterial infections and is not significantly influenced by seasonal changes.

Choice E rationale:

Mycoplasma pneumoniae infection is not a common cause of epiglottitis.

Bacterial infections, especially Hib, are the primary culprits in pediatric cases of epiglottitis.

Choice A rationale:

Epiglottitis is not necessarily more common in females than in males.

It can affect both genders equally.

Choice B rationale:

While epiglottitis is more common in children, it primarily affects those between the ages of 2 and 8 years old, not just infants under 1 year old.

Choice C rationale:

There is no significant evidence to suggest that epiglottitis is more prevalent in colder months.

The occurrence of epiglottitis is not strictly related to seasonal changes.

Choice D rationale:

Children between 2 and 8 years old are at higher risk of developing epiglottitis.

This age group is more susceptible due to their smaller airways and less developed immune systems, making them prone to infections like epiglottitis.

Choice A rationale:

Streptococcus pneumoniae is a common bacterium associated with respiratory infections, but it is not the most common causative agent of epiglottitis in children.

Choice B rationale:

Staphylococcus aureus can cause various infections, but it is not the primary causative agent of epiglottitis in children.

Choice C rationale:

Haemophilus influenzae type b (Hib) is the most common causative agent of epiglottitis in children.

Hib infection can lead to inflammation and swelling of the epiglottis, causing the characteristic symptoms of epiglottitis, including difficulty swallowing and a muffled voice.

Choice D rationale:

Neisseria meningitidis is a bacterium that can cause meningitis and septicemia, but it is not the main causative agent of epiglottitis.

Choice A rationale:

Difficulty swallowing and throat pain are common symptoms of epiglottitis, but they do not necessarily indicate the severity of the condition.

Choice B rationale:

Feeling anxious and restless may be a sign of distress, but it does not specifically indicate the severity of epiglottitis.

Choice C rationale:

Making a high-pitched sound when breathing (called stridor) is a serious symptom indicating airway obstruction.

While this is concerning, it is not the most critical manifestation in evaluating the severity of epiglottitis.

Choice D rationale:

Cyanosis, characterized by a bluish discoloration of the skin and lips, indicates severe lack of oxygen and is a critical sign in assessing the severity of epiglottitis.

Cyanosis suggests inadequate oxygenation and is indicative of impending respiratory failure, requiring immediate medical intervention.

Choice A rationale:

The statement "My throat is really sore.”.

is a common symptom of throat infections, including epiglottitis.

While it is concerning, it is not the most concerning symptom in this case.

Epiglottitis can rapidly progress, leading to respiratory distress, which is a life-threatening condition.

Choice B rationale:

The statement "I can't stop drooling.”.

is a significant concern in a child suspected of having epiglottitis.

Drooling and difficulty managing secretions are hallmark signs of epiglottitis and indicate compromised airway protection.

This symptom suggests that the epiglottis is inflamed and obstructing the airway, potentially leading to respiratory distress and the need for urgent intervention.

Choice C rationale:

The statement "I feel restless and agitated.”.

is a non-specific symptom and may be seen in various illnesses, including infections.

While it indicates the child's discomfort, it does not directly point to the severity of the condition or airway compromise, making it less concerning than the inability to handle secretions.

Choice D rationale:

The statement "I'm having trouble breathing.”.

is the most concerning symptom in a child suspected of having epiglottitis.

Difficulty breathing indicates significant airway obstruction, which can rapidly progress to respiratory failure.

This symptom requires immediate medical attention and intervention to secure the airway and prevent further complications.

Choice A rationale:

Drooling and inability to handle secretions are characteristic manifestations of epiglottitis.

Inflamed epiglottis impairs the child's ability to swallow and manage saliva, leading to drooling.

This symptom is a key clinical indicator of epiglottitis.

Choice B rationale:

Cough and wheezing are not typical manifestations of epiglottitis.

Epiglottitis primarily affects the upper airway, leading to symptoms such as drooling, stridor, and respiratory distress.

Cough and wheezing are more common in lower respiratory tract infections, such as bronchitis or pneumonia.

Choice C rationale:

Cyanosis and pallor are not specific to epiglottitis and can occur in various respiratory and cardiovascular conditions.

While these symptoms indicate decreased oxygenation, they are not unique to epiglottitis and are not considered characteristic manifestations of this condition.

Choice D rationale:

Muffled voice and stridor are characteristic signs of epiglottitis.

A muffled voice occurs due to the swollen epiglottis obstructing airflow, resulting in a change in the sound of the child's voice.

Stridor is a high-pitched, noisy breathing sound that occurs during inspiration and indicates partial airway obstruction.

Both symptoms are indicative of compromised upper airway in epiglottitis.

Choice E rationale:

Tachypnea (rapid breathing) and tachycardia (rapid heartbeat) are common physiological responses to respiratory distress.

In epiglottitis, the child may exhibit these symptoms due to the body's attempt to compensate for decreased oxygen levels.

These manifestations reflect the severity of the condition and the child's physiological response to airway compromise.

Choice A rationale:

Computed tomography (CT) scan provides detailed images of internal structures but is not the preferred imaging test for visualizing a swollen epiglottis.

CT scans are more commonly used for evaluating conditions in other parts of the body, such as the brain or abdomen, and may not provide the necessary detail for assessing the upper airway.

Choice B rationale:

Magnetic resonance imaging (MRI) can produce high-resolution images of soft tissues, but it is not the first choice for visualizing a swollen epiglottis.

MRI scans are time-consuming and may not be readily available in urgent situations.

In cases of suspected epiglottitis, prompt diagnosis and intervention are crucial to prevent respiratory compromise.

Choice C rationale:

Lateral neck radiograph is the preferred imaging test for visualizing a swollen epiglottis.

This X-ray technique allows healthcare providers to assess the size of the epiglottis and its relationship with nearby structures.

A classic finding in epiglottitis on a lateral neck radiograph is a swollen epiglottis, giving a thumbprint sign appearance.

This imaging study can aid in the diagnosis and guide appropriate management.

Choice D rationale:

X-ray of the chest is not the preferred imaging test for evaluating epiglottitis.

While a chest X-ray can provide information about the lungs and surrounding structures, it does not offer the necessary detail to visualize the upper airway, including the epiglottis.

Lateral neck radiograph is specifically tailored to assess the structures in the throat region and is the imaging modality of choice in suspected cases of epiglottitis.

Choice A rationale:

Allergies to foods are not directly related to epiglottitis.

While it's essential information for a general health assessment, it doesn't provide specific insights into the condition.

Choice B rationale:

Immunization history is crucial in the assessment of a child with suspected epiglottitis.

Haemophilus influenzae type b (Hib) vaccination is highly effective in preventing epiglottitis caused by Hib bacteria.

Knowing the child's immunization status helps the nurse assess the likelihood of Hib infection.

Choice C rationale:

Recent travel destinations are not directly relevant to epiglottitis.

This information is more pertinent when assessing the risk of diseases like malaria or dengue fever, which are region-specific.

Choice D rationale:

Current hobbies and interests are not pertinent to the assessment of epiglottitis.

This information is important in a broader context for understanding the child's lifestyle but does not provide relevant data regarding the condition.

Choice A rationale:

Administering antibiotics intravenously is important in treating the infection, but it doesn't directly address maintaining a patent airway.

The priority in epiglottitis is to ensure an open airway to prevent respiratory distress.

Choice B rationale:

Providing humidified air or cool mist therapy helps moisten the airway, making it easier for the child to breathe.

This intervention can provide immediate relief and aid in maintaining a patent airway, which is crucial in epiglottitis.

Choice C rationale:

Administering corticosteroids intravenously can help reduce inflammation, but it might not be the primary intervention to maintain a patent airway.

Humidified air therapy directly addresses airway moisture, which is essential in epiglottitis management.

Choice D rationale:

Administering analgesics and antipyretics can address pain and fever associated with epiglottitis but does not directly contribute to maintaining a patent airway.

While these medications can improve the child's comfort, they are not the priority in this situation.

Choice A rationale:

The importance of oral medications to relieve symptoms is relevant, but it doesn't specifically prevent epiglottitis.

Preventive measures like vaccination are more crucial in avoiding the condition.

Choice B rationale:

Educating the child and their family about the signs and symptoms of epiglottitis is essential for early recognition and prompt medical intervention.

Understanding the symptoms can lead to quicker medical attention, which is vital in managing epiglottitis effectively.

Choice C rationale:

Avoiding complete immunization against Hib is not a recommended practice.

Hib vaccination significantly reduces the risk of epiglottitis caused by Hib bacteria.

Encouraging complete immunization is a key preventive measure against the disease.

Choice D rationale:

Using nebulized medications for treatment might be a part of the management plan if the child already has epiglottitis, but it's not a preventive measure.

Prevention focuses on vaccination and awareness of symptoms, making choice D less relevant in the context of prevention.

Choice A rationale:

Administering antibiotics intravenously as prescribed is a crucial intervention in the management of epiglottitis.

Epiglottitis is commonly caused by bacterial infections, and intravenous antibiotics are essential to target the underlying infection and prevent its spread.

The choice of antibiotic should be based on the specific causative organism and local antibiotic resistance patterns.

Choice B rationale:

Administering corticosteroids intravenously as prescribed is another important intervention in the supportive care of epiglottitis.

Corticosteroids help reduce airway inflammation, which is a significant concern in epiglottitis.

By decreasing inflammation, corticosteroids can alleviate respiratory distress and improve the patient's breathing.

Choice C rationale:

Providing hydration and nutrition by intravenous fluids is necessary in the management of epiglottitis, especially if the child is having difficulty swallowing or breathing.

Intravenous fluids ensure that the child receives adequate hydration and nutrition while minimizing the risk of aspiration, which can worsen the airway obstruction.

Choice E rationale:

Providing humidified air or cool mist therapy to moisten the airway is a supportive measure that can help ease breathing difficulties in children with epiglottitis.

Humidified air or cool mist therapy can soothe the inflamed airway, making it easier for the child to breathe.

It is essential to maintain a moist environment to prevent further irritation and discomfort.

Choice D rationale:

Educating the child and family about the prevention of epiglottitis is important for overall health awareness, but it is not a direct supportive intervention for a child already diagnosed with the condition.

While prevention strategies, such as timely vaccinations and good hygiene, are crucial, they do not constitute immediate supportive care for a child with active epiglottitis.

Choice A rationale:

Tracheostomy may be necessary in severe cases of epiglottitis where the airway obstruction is life-threatening and cannot be managed with other interventions.

In such cases, creating a surgical airway via tracheostomy can provide a more stable and secure airway, ensuring adequate oxygenation.

However, this option is typically considered when other measures, such as intubation, have failed or are not feasible due to the severity of the obstruction.

Choice B rationale:

Intubation may be required in cases where the airway obstruction is significant, and the child is unable to maintain oxygenation and ventilation adequately.

Intubation allows for mechanical ventilation, ensuring a patent airway and adequate oxygen supply.

However, it is not always the only option and may depend on the severity of the condition and the response to other interventions.

Choice C rationale:

Tracheostomy is more invasive than intubation.

While tracheostomy is a surgical procedure that involves creating an opening in the trachea, intubation involves inserting a tube through the mouth or nose into the trachea.

Tracheostomy is considered more invasive because it requires a surgical incision and the placement of a permanent or temporary tracheostomy tube.

Choice D rationale:

Intubation is not always the first choice for airway management in epiglottitis.

The choice of airway management (intubation, tracheostomy, or other interventions) depends on the severity of the airway obstruction, the child's clinical condition, and the healthcare provider's assessment.

Intubation may be chosen if the obstruction is significant and the child cannot maintain adequate oxygenation and ventilation.

Choice A rationale:

The nurse should monitor for signs of adrenal insufficiency and hyperglycemia as potential side effects of corticosteroid therapy.

Corticosteroids can suppress the adrenal glands, leading to adrenal insufficiency, which can manifest as weakness, fatigue, low blood pressure, and abdominal pain.

Hyperglycemia (elevated blood sugar levels) is a common side effect of corticosteroids and can worsen diabetes or predispose non-diabetic individuals to high blood sugar levels.

Choice B rationale:

Decreased oxygen saturation levels are not a common side effect of corticosteroid therapy.

Corticosteroids help reduce airway inflammation, which can actually improve oxygenation in conditions like epiglottitis by reducing airway obstruction and respiratory distress.

Choice C rationale:

Allergic reactions to corticosteroids are possible, but they are relatively rare.

Symptoms of an allergic reaction can include rash, itching, swelling, severe dizziness, or difficulty breathing.

While allergic reactions are a concern with any medication, they are not the primary side effect that nurses should monitor for when administering corticosteroids.

Choice D rationale:

Increased sensitivity to antibiotics is not a known side effect of corticosteroid therapy.

Corticosteroids work by suppressing the immune response and reducing inflammation, but they do not affect the body's sensitivity to antibiotics.

Antibiotic effectiveness is determined by factors such as the specific antibiotic used, the type of bacteria causing the infection, and antibiotic resistance patterns.

Choice A rationale:

Otitis media is not mainly caused by the presence of bacteria in the middle ear.

While bacterial infections can contribute to otitis media, it is not the primary cause as per the information provided in the text.

Choice B rationale:

Eustachian tube dysfunction is indeed the primary cause of otitis media.

The Eustachian tube connects the middle ear to the back of the throat.

When this tube is not functioning correctly, it can lead to the accumulation of fluid in the middle ear, providing an ideal environment for bacterial growth and infection, which results in otitis media.

Choice C rationale:

Otitis media is not primarily caused by allergic reactions.

While allergies can lead to Eustachian tube dysfunction, it is not the main cause of otitis media.

Choice D rationale:

The statement that "The risk factors for otitis media are not well-defined" is incorrect.

The risk factors for otitis media are well-established, including factors like age (more common in children), exposure to smoke, attending daycare, and Eustachian tube abnormalities.

Choice A rationale:

Otitis media is more common in young children, especially those between 6 months and 3 years of age.

It is not more common in children over 6 years of age.

Choice B rationale:

Seasonal changes can indeed impact the frequency of otitis media.

During cold seasons, upper respiratory infections are more common, which can lead to otitis media.

Choice C rationale:

Noncompliance with vaccinations is associated with otitis media.

Proper vaccination can prevent certain infections that may lead to otitis media.

Choice D rationale:

Passive smoking can increase the risk of otitis media.

Exposure to secondhand smoke can cause irritation and inflammation in the Eustachian tubes, making individuals, especially children, more susceptible to ear infections.

Choice A rationale:

Eustachian tube obstruction does lead to decreased pressure in the middle ear.

When the Eustachian tube is blocked or not functioning properly, it can create a vacuum in the middle ear, leading to negative pressure, which can pull fluid into the middle ear space.

Choice B rationale:

Effusion is indeed the fluid that fills the normally air-filled middle ear cavity in otitis media.

This fluid can accumulate due to Eustachian tube dysfunction or inflammation, leading to the characteristic symptoms of otitis media.

Choice C rationale:

Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis are indeed common pathogens causing otitis media.

These bacteria can infect the middle ear and lead to the inflammation and fluid accumulation characteristic of otitis media.

Choice D rationale:

Otitis media does not result from the inflammation of the outer ear.

Otitis media specifically refers to inflammation and infection of the middle ear.

Choice E rationale:

The statement about the eardrum becoming red, swollen, and bulging due to the absence of effusion is incorrect.

The presence of effusion behind the eardrum can cause it to appear red, swollen, and bulging, not the absence of effusion.

Choice A rationale:

Migraines and tension headaches are not mentioned as complications of otitis media in the text.

Otitis media primarily affects the middle ear and is associated with complications related to the ear and hearing.

Choice B rationale:

Chronic back pain and joint issues are unrelated to otitis media.

The complications of otitis media are primarily associated with the ear, hearing, and speech.

Choice C rationale:

Speech delay and hearing loss are mentioned as potential consequences of otitis media.

Otitis media can lead to hearing impairment, especially in children, which can subsequently cause speech delays.

This complication occurs due to the accumulation of fluid in the middle ear, which impairs the normal conduction of sound.

Choice D rationale:

Skin rashes and allergic reactions are not mentioned as consequences of otitis media.

Complications of otitis media primarily revolve around the auditory system and related functions.

Choice A rationale:

Age alone is not a risk factor for otitis media.

However, certain age groups, such as young children, are more susceptible to ear infections due to their developing immune systems and shorter Eustachian tubes.

Choice B rationale:

Season is not a direct risk factor for otitis media.

While certain respiratory infections might be more common in specific seasons, otitis media itself is not strongly influenced by seasonal changes.

Choice C rationale:

Allergies can contribute to ear infections, but they are not the most closely associated risk factor mentioned in the context.

Allergies can lead to inflammation and fluid buildup in the middle ear, making individuals more prone to infections.

However, in the given options, day care attendance is a more specific risk factor related to exposure to infectious agents.

Choice D rationale:

Day care attendance is closely associated with an increased exposure to infectious agents, including the bacteria that can cause otitis media.

Children in day care settings are in close contact with others, facilitating the spread of infections.

and "Balance problems result from serous fluid in the ear canal.”.

Choice A rationale:

The statement that "The ear pain is usually mild and intermittent" is incorrect.

Ear pain associated with acute otitis media (AOM) is often severe and continuous, causing discomfort and distress to the affected individual.

Choice B rationale:

Irritability, manifested as crying or fussiness, is a common symptom of AOM.

Ear pain and pressure can cause considerable discomfort, leading to irritability and changes in behavior, especially in children.

Choice C rationale:

The statement "Hearing loss in AOM is typically severe" is incorrect.

While hearing loss can occur in AOM, it is not always severe.

The degree of hearing impairment can vary based on the severity of the infection and the presence of fluid in the middle ear.

Choice D rationale:

Balance problems resulting from serous fluid in the ear canal are correct.

Serous fluid buildup in the middle ear can affect the balance mechanisms, leading to balance issues and dizziness, especially in children.

This fluid buildup can cause pressure changes, impacting the normal functioning of the inner ear.

Choice E rationale:

Otorrhea, which refers to discharge from the ear, is not a common symptom of AOM.

Otorrhea is more commonly associated with chronic ear infections or other ear conditions but not necessarily with acute otitis media.

Choice A rationale:

A history of frequent episodes of otitis media is important to inquire about because recurrent ear infections are a common sign of otitis media.

Children who have experienced multiple episodes of otitis media are at a higher risk for developing the condition again.

This information helps the nurse assess the child's susceptibility to ear infections and guides further evaluation and treatment decisions.

Choice B rationale:

Previous upper respiratory tract infections are relevant to the child's overall health but are not specific symptoms of otitis media.

Otitis media can be a complication of upper respiratory infections, but the presence of previous infections alone does not confirm otitis media.

Choice C rationale:

Exposure to loud noise as a daily occurrence is not a symptom of otitis media.

Otitis media is an inflammation of the middle ear, commonly caused by bacterial or viral infections, and is not related to exposure to loud noises.

Choice D rationale:

A feeling of fullness or pressure in the ear can be associated with otitis media, but it is a nonspecific symptom that can occur in various ear conditions.

While it may raise suspicion, it is not a definitive sign of otitis media.

Choice E rationale:

Immunization history of the child is important for the child's overall health, but it is not a specific symptom of otitis media.

Immunizations do not directly influence the development or presence of otitis media.

Choice A rationale:

Redness of the tympanic membrane can indicate inflammation, which is a common sign of acute otitis media (AOM).

Inflammation causes increased blood flow to the area, leading to redness and often pain.

Choice B rationale:

Bulging of the tympanic membrane occurs when there is increased pressure behind the eardrum, often due to fluid accumulation.

In the context of acute otitis media, this bulging is caused by the buildup of pus or other fluids in the middle ear.

Choice C rationale:

Purulence (pus) observed in the ear canal is a definitive sign of acute otitis media.

The presence of pus indicates an active infection within the middle ear.

Choice D rationale:

Orange discoloration of the tympanic membrane is not a typical finding in acute otitis media.

The color change could be due to various factors but is not specific to this condition.

Choice E rationale:

Decreased mobility of the tympanic membrane can occur due to the accumulation of fluid in the middle ear, leading to impaired movement.

This decreased mobility is often observed in acute otitis media and contributes to the diagnosis.

Choice A rationale:

The child reporting severe, throbbing ear pain is more indicative of acute otitis media (AOM) rather than otitis media with effusion (OME).

Severe pain is a common symptom of an active infection in the middle ear.

Choice B rationale:

Pus observed draining from the ear canal is a sign of acute otitis media (AOM).

Drainage indicates a ruptured eardrum, allowing the infected fluid to escape, relieving pressure and pain.

Choice C rationale:

Hearing loss that is mild to moderate is characteristic of otitis media with effusion (OME).

OME occurs when fluid remains trapped in the middle ear after the infection has resolved.

The presence of fluid can affect hearing, especially at lower frequencies, leading to mild to moderate hearing loss.

Choice D rationale:

The eardrum appearing red and bulging is a typical finding in acute otitis media (AOM), not otitis media with effusion (OME).

In AOM, the eardrum becomes red due to inflammation and bulges due to increased pressure from fluid buildup.

"Difficulty locating sounds or following directions.”.

Choice A rationale:

Difficulty locating sounds or following directions is a common sign of hearing loss in children with otitis media.

Hearing loss can affect a child's ability to hear and process sounds, leading to problems in locating the source of sounds or following instructions.

This manifestation is indicative of conductive hearing loss, which is commonly associated with otitis media.

Children may have trouble understanding speech, especially in noisy environments.

Choice B rationale:

Ringing or buzzing sound in the ear, also known as tinnitus, is not a typical manifestation of hearing loss in otitis media.

Tinnitus can occur due to various reasons, but it is not a specific indicator of hearing loss associated with otitis media.

Choice C rationale:

Severe, pulsating ear pain is a symptom of acute otitis media, but it is not directly indicative of hearing loss.

Ear pain is caused by the buildup of fluid and pressure in the middle ear, leading to discomfort and pain.

However, it does not necessarily mean the child has hearing loss.

Choice D rationale:

Vertigo and nystagmus are symptoms associated with inner ear disorders, such as vestibular labyrinthitis or Meniere's disease, but they are not typical manifestations of hearing loss in otitis media.

These symptoms involve problems with balance and coordination and are not directly related to hearing loss.

Choice E rationale:

Inconsolable crying due to discomfort is a general symptom that can occur in children with various illnesses, including otitis media.

While it indicates the child is in pain or discomfort, it is not a specific sign of hearing loss.

Children may cry due to ear pain, but this symptom alone does not confirm hearing loss.

"The pain gets worse when I lie down.”.

Choice A rationale:

"I feel a sharp pain in my ear sometimes.”.

This statement suggests intermittent ear pain, which can occur in otitis media when there is a sudden change in pressure in the middle ear.

It is a possible symptom, but it is not specific to otitis media as other ear conditions can also cause sharp ear pain.

Choice B rationale:

"My ear hurts all the time.”.

Constant ear pain is a common symptom of acute otitis media.

The pain is caused by inflammation and pressure in the middle ear.

This symptom is indicative of otitis media but does not provide specific information about the pain worsening when lying down, which is a crucial aspect to assess.

Choice C rationale:

"The pain gets worse when I lie down.”.

This statement is indicative of otitis media.

When the child lies down, the fluid in the middle ear can put additional pressure on the eardrum, causing increased pain.

This worsening of pain in specific positions helps differentiate otitis media from other ear conditions.

Choice D rationale:

"I have no pain in my ear.”.

Absence of ear pain is not consistent with otitis media.

Otitis media is characterized by ear pain, especially in acute cases when there is inflammation and pressure in the middle ear.

Lack of ear pain suggests the absence of this condition.

"I have a high fever, and I'm shivering.”.

Choice A rationale:

"I have a high fever, and I'm shivering.”.

A high fever with chills indicates a systemic response to infection, which can be seen in severe cases of otitis media.

Fever is a common symptom and can indicate a spreading or worsening infection.

Shivering (rigors) often accompanies a high fever and suggests a significant inflammatory response in the body.

Choice B rationale:

"I feel warm, but I'm not sweating.”.

Feeling warm without sweating may indicate a low-grade fever, which can occur in various infections, including otitis media.

However, this statement does not provide information about the severity of the fever or the child's overall condition.

Choice C rationale:

"I'm sweating a lot, and I'm very tired.”.

Sweating and fatigue can be symptoms of various illnesses, including infections.

Sweating, especially if accompanied by other symptoms like fever, can indicate a fever breaking, but it does not specifically provide information about the severity of the infection or its relationship to otitis media.

Choice D rationale:

"I don't have a fever at all.”.

The absence of fever is not consistent with acute otitis media.

Fever is a common systemic response to infection and inflammation.

In the context of otitis media, the presence of fever indicates a more severe or active infection.

Choice A rationale:

The nurse should consider the results of the whisper test when assessing a child with otitis media.

A whisper test helps to assess hearing acuity and can indicate if there is a hearing impairment in the child.

If the child does not respond appropriately to the whisper test, it could suggest hearing problems related to otitis media.

Choice B rationale:

Assessing the child's response to sounds is crucial in evaluating their hearing abilities.

Children with otitis media may have difficulty hearing soft sounds or may not respond appropriately to auditory stimuli.

This assessment finding can provide valuable information about the child's hearing status and potential issues related to otitis media.

Choice D rationale:

Considering the child's history of hearing problems is essential in understanding the overall context of their ear health.

A history of recurrent ear infections or hearing difficulties can indicate a chronic issue, such as otitis media, which the nurse needs to address and monitor closely.

Past hearing problems can influence the current assessment and guide appropriate interventions.

Choice C rationale:

Temperature measurement is not directly related to assessing a child with otitis media.

Otitis media primarily affects the middle ear, leading to symptoms such as ear pain, hearing loss, and sometimes drainage from the ear.

Monitoring the child's temperature is important for assessing fever, which could be a sign of infection, but it is not specific to otitis media assessment.

Choice E rationale:

Lip reading skills are not typically assessed in the context of otitis media.

Otitis media primarily affects the auditory system, leading to hearing difficulties.

While lip reading skills might be relevant for individuals with profound hearing loss, it is not a standard assessment for children with otitis media, especially during a comprehensive assessment.

Choice A rationale:

The statement "I sometimes feel dizzy and unsteady" indicates balance problems in the child.

Balance issues can occur in individuals with otitis media due to disturbances in the inner ear, affecting the vestibular system responsible for balance and spatial orientation.

Dizziness and unsteadiness are common symptoms associated with inner ear problems, including otitis media.

Therefore, this statement should be evaluated further to assess the child's balance and related concerns.

Choice B rationale:

The statement "My ear feels heavy" is related to a sensation in the ear and does not specifically indicate balance problems.

While otitis media can cause ear discomfort and pain, the sensation of heaviness alone does not provide information about the child's balance issues.

It is important to differentiate between symptoms related to ear discomfort and those indicating problems with balance.

Choice C rationale:

The statement "I have trouble swallowing" is not directly related to balance problems associated with otitis media.

Swallowing difficulties are typically not a primary symptom of otitis media.

This statement might indicate issues with the throat or esophagus but does not provide relevant information about the child's balance concerns.

Choice D rationale:

The statement "I can balance perfectly" suggests that the child does not experience balance problems.

This statement contradicts the typical symptoms associated with otitis media, which can include dizziness, unsteadiness, and balance issues.

If the child can balance perfectly, it indicates that their vestibular system, responsible for balance, is functioning normally and is not affected by otitis media.

The correct answer is Choice B: Antivirals.

Choice A rationale:

Watchful waiting is a valid approach, especially for mild cases of otitis media, allowing time to see if the condition improves on its own.

Choice B rationale:

Antivirals are not typically used to manage otitis media because it is usually caused by bacterial infections or fluid buildup rather than viruses.

Choice C rationale:

Myringotomy, which involves creating a small incision in the eardrum to drain fluid, is an effective treatment for recurrent or severe cases of otitis media.

Choice D rationale:

Administration of over-the-counter pain relievers helps manage pain and discomfort associated with otitis media and is a common recommendation.

Choice A rationale:

The parent's statement, "Yes, my child has had frequent diarrhea," is expected in a child with gastroenteritis caused by a viral infection.

Viral gastroenteritis often presents with symptoms like diarrhea, vomiting, stomach pain, and sometimes fever.

Frequent, watery diarrhea is a common characteristic of viral gastroenteritis in children.

The nurse should be aware of this symptom to provide appropriate care, including rehydration and monitoring for signs of dehydration.

Choice B rationale:

The statement, "No, my child's bowel movements are normal," would not be an expected response from the parent of a child with gastroenteritis.

As mentioned earlier, viral gastroenteritis typically causes changes in bowel habits, leading to frequent diarrhea.

Choice C rationale:

The statement, "My child has been constipated," is not consistent with the symptoms of gastroenteritis.

Constipation involves infrequent and difficult bowel movements, which are not typical symptoms of viral gastroenteritis.

Choice D rationale:

The statement, "My child has been vomiting a lot," is a symptom of gastroenteritis.

However, the question specifically asks about changes in bowel movements.

While vomiting is a common symptom of gastroenteritis, the focus here is on bowel movements, making choice A The correct answer.

Choice D rationale:

The statement, "My child has had diarrhea for a few days," is a potential statement the nurse might hear during the assessment of a child with gastroenteritis.

Diarrhea is a common symptom of viral gastroenteritis and can lead to dehydration if not properly managed.

The nurse should assess the duration, frequency, and characteristics of the diarrhea to determine the severity of the condition and plan appropriate interventions.

Choice A rationale:

The statement, "My child has been eating and drinking normally," does not align with the symptoms described by the client.

Children with gastroenteritis often have decreased appetite and may not tolerate normal food and fluid intake due to nausea, vomiting, and diarrhea.

Choice B rationale:

The statement, "My child's bowel movements have been regular," contradicts the reported symptoms of diarrhea and stomach pain.

Regular bowel movements are not expected in a child with gastroenteritis, which commonly causes loose or watery stools.

Choice C rationale:

The statement, "My child hasn't had any abdominal discomfort," is not consistent with the typical symptoms of gastroenteritis.

Abdominal discomfort, cramping, and pain are common complaints in individuals with gastroenteritis, especially during episodes of diarrhea.

Choice A rationale:

Ensuring proper handwashing before meals and after using the toilet is an effective prevention strategy for gastroenteritis.

Proper hand hygiene helps prevent the spread of viral and bacterial infections, including those causing gastroenteritis.

Choice D rationale:

Advising parents to keep their child away from sick individuals is another effective prevention strategy.

Gastroenteritis is highly contagious and can spread through close contact with infected individuals.

Avoiding contact with sick individuals reduces the risk of exposure to the viruses or bacteria causing gastroenteritis.

Choice E rationale:

Recommending vaccination against common viral causes of gastroenteritis is a preventive measure.

Vaccines are available for certain viruses, such as rotavirus, which is a common cause of gastroenteritis in children.

Immunization helps protect children from severe cases of gastroenteritis and reduces the overall prevalence of the disease in the community.

Choice B rationale:

Encouraging the sharing of utensils among children to build immunity is not a recommended strategy for preventing gastroenteritis.

Sharing utensils can increase the risk of spreading infections, including gastroenteritis.

Proper hygiene practices, such as using separate utensils and avoiding sharing drinks and food, are essential to prevent the transmission of the disease.

Choice C rationale:

Promoting the consumption of untreated stream water during outdoor activities is not a safe practice.

Untreated water sources, including streams, can contain harmful bacteria, parasites, and other pathogens that can cause gastroenteritis and other waterborne illnesses.

Encouraging children to drink clean, treated water from safe sources is important to prevent gastrointestinal infections.

Choice A rationale:

Gastroenteritis does not cause the intestines to absorb excess fluids.

In fact, it does the opposite by decreasing absorption and increasing fluid secretion, leading to diarrhea.

Choice B rationale:

This statement is incorrect.

Gastroenteritis does not inhibit fluid secretion; instead, it damages the intestines, causing increased fluid secretion and decreased absorption, which results in diarrhea.

Choice C rationale:

The correct answer.

Gastroenteritis, especially the infectious type, damages the intestines.

The infection leads to decreased absorption of fluids and increased fluid secretion, causing diarrhea.

Choice D rationale:

This statement is inaccurate.

Gastroenteritis does impact fluid balance in the intestines.

It disrupts the normal functioning of the intestines, leading to fluid imbalances.

Choice A rationale:

Fungal infections are not a common cause of gastroenteritis in children.

Viral, bacterial, and parasitic infections are the primary culprits.

Choice B rationale:

Exposure to cold weather is not a direct cause of gastroenteritis.

The condition is mainly caused by infections, as mentioned in choice C.

Choice C rationale:

The correct answer.

Gastroenteritis in children is commonly caused by viral, bacterial, and parasitic infections.

These microorganisms can lead to inflammation of the gastrointestinal tract, resulting in symptoms like diarrhea and vomiting.

Choice D rationale:

Gastroenteritis is generally not caused by food allergies in children.

While food allergies can cause gastrointestinal symptoms, the typical presentation of gastroenteritis involves infectious agents rather than allergic reactions.

Choice A rationale:

The correct answer.

Stool culture and sensitivity testing are essential diagnostic tests for identifying the causative organism in bacterial infections related to gastroenteritis.

This test helps determine the specific bacteria causing the infection and their susceptibility to antibiotics, guiding appropriate treatment.

Choice B rationale:

Blood tests to assess kidney function are not specific to diagnosing gastroenteritis or its causative organism.

These tests are more relevant in assessing kidney-related issues.

Choice C rationale:

Imaging studies such as abdominal ultrasound are not the primary diagnostic tests for identifying the causative organism in gastroenteritis.

These studies are used for visualizing the internal structures of the abdomen and may not provide specific information about the infectious agent.

Choice D rationale:

Viral testing using polymerase chain reaction (PCR) is valuable for detecting viruses, but it is not the first-line diagnostic test for bacterial infections related to gastroenteritis.

Stool culture and sensitivity testing are more appropriate in this context.

Choice A rationale:

The child's fever is not the most reliable indicator of hydration status.

While fever can indicate an infection, it does not provide direct information about the child's hydration level.

Choice B rationale:

The frequency of stools is relevant to gastroenteritis but does not provide a comprehensive assessment of hydration status.

Dehydration can occur even if the child is having frequent stools.

Choice C rationale:

The child's abdominal pain level is important but does not directly assess hydration status.

Abdominal pain is a symptom of gastroenteritis, but it does not provide specific information about the child's hydration level.

Choice D rationale:

Skin turgor, mucous membranes, and urine output are crucial indicators of hydration status.

Skin turgor refers to the skin's elasticity and how quickly it returns to normal after being pinched.

Poor skin turgor can indicate dehydration.

Mucous membranes, such as the inside of the mouth, should be moist.

Dry mucous membranes can suggest dehydration.

Additionally, monitoring urine output is essential.

A decreased urine output or dark-colored urine can indicate dehydration.

These parameters provide a comprehensive assessment of the child's hydration status and guide appropriate interventions.

Choice A rationale:

The child's weight and height are essential for assessing growth and nutritional status.

Changes in weight and height can indicate malnutrition or other health issues.

Choice B rationale:

Documentation of stool characteristics is crucial in assessing gastrointestinal issues such as gastroenteritis.

Characteristics like color, consistency, and presence of blood or mucus can provide important diagnostic information.

Choice C rationale:

Assessment of skin turgor is relevant for hydration status but is not specific to gastroenteritis.

While decreased skin turgor can indicate dehydration, other factors like mucous membranes and urine output are more specific indicators for gastroenteritis-related dehydration.

Choice D rationale:

Monitoring the child's temperature is essential to identify fever, which is a common symptom of gastroenteritis and can indicate infection or inflammation.

Choice E rationale:

Evaluating the child's overall appearance and behavior is crucial.

Lethargy, irritability, or other changes in behavior can indicate dehydration or worsening illness.

Additionally, observing the child's general appearance can provide valuable information about their overall health status.

Choice A rationale:

"In gastroenteritis, diarrhea is often bloody and mucus-filled.”.

This statement is incorrect.

While gastroenteritis can cause loose stools, they are usually watery rather than bloody or mucus-filled.

Bloody or mucus-filled stools might indicate other gastrointestinal issues that need further evaluation.

Choice B rationale:

"Diarrhea in gastroenteritis is typically chronic and persistent.”.

This statement is incorrect.

Gastroenteritis often presents with acute symptoms, including sudden onset of diarrhea, vomiting, and abdominal pain.

Chronic and persistent diarrhea might suggest other chronic gastrointestinal conditions but is not characteristic of gastroenteritis.

Choice C rationale:

"Gastroenteritis usually presents with constipation.”.

This statement is incorrect.

Gastroenteritis typically presents with diarrhea, not constipation.

Constipation is the opposite of diarrhea and is not a symptom associated with gastroenteritis.

Choice D rationale:

"The diarrhea in gastroenteritis is usually watery.”.

This statement is correct.

Watery diarrhea is a hallmark symptom of gastroenteritis.

It results from inflammation of the gastrointestinal tract, leading to increased water content in the stools.

This type of diarrhea can quickly lead to dehydration if not managed promptly.

Choice A rationale:

The Pediatric Assessment Tool is a broad term and doesn't specify a particular pain assessment method.

It's not the best choice in this context.

Choice B rationale:

The Wong-Baker FACES Pain Rating Scale is a widely used and validated tool for assessing pain in children, especially those who might have difficulty expressing their pain verbally.

It uses facial expressions as indicators of pain levels, making it particularly useful for young children.

Choice C rationale:

The Numeric Pain Rating Scale is a numerical scale from 0 to 10 where patients rate their pain intensity.

While it can be used for children, the Wong-Baker FACES Pain Rating Scale is more child-friendly and visually oriented.

Choice D rationale:

The Visual Analog Scale (VAS) is a continuous scale used for pain assessment.

It's more suitable for adults and older children, as younger children might find it challenging to understand and use effectively.

Choice A rationale:

Oral rehydration therapy (ORT) is a key treatment for gastroenteritis.

It helps to replace lost fluids and electrolytes due to vomiting and diarrhea, preventing dehydration.

The primary goal of ORT is to control these symptoms and maintain hydration.

Choice B rationale:

While ORT does treat the consequences of the infection (dehydration), it doesn't directly treat the underlying cause, which is often a viral or bacterial infection.

Choice C rationale:

ORT does prevent dehydration, which is a complication of gastroenteritis, but it doesn't specifically prevent the spread of the infection to others.

Choice D rationale:

ORT can often prevent the need for hospitalization by effectively managing dehydration on an outpatient basis.

However, its primary purpose is to prevent dehydration, not to eliminate the need for hospitalization in all cases.

Choice A rationale:

Prescribing an antiemetic might be necessary in some cases, but the immediate concern is to manage the client's thirst and fluid intake.

Trying to control vomiting is secondary to ensuring hydration.

Choice B rationale:

Avoiding any fluid intake can lead to dehydration, especially if the client is experiencing severe vomiting.

This option is not appropriate and can worsen the client's condition.

Choice C rationale:

Starting with a clear liquid diet is a standard approach in managing gastroenteritis.

Clear liquids are easier to digest and can help assess the client's ability to tolerate oral intake.

If the client can tolerate clear liquids without vomiting, it indicates a positive step toward hydration and nutritional intake.

Choice D rationale:

Drinking as much water as possible might not be appropriate, especially if the client is vomiting severely.

Introducing clear liquids first allows for a gradual reintroduction of fluids and assesses the client's tolerance before advancing to more complex diets.

Choice A rationale:

Instructing the parents to teach the child to cover their mouth and nose when coughing or sneezing is crucial in preventing the spread of infections, especially in cases of gastroenteritis.

This measure helps in containing respiratory droplets that might carry the virus or bacteria causing the illness.

Choice B rationale:

Isolating the child in a separate room away from other family members is essential to prevent the transmission of the disease to others in the household.

Gastroenteritis spreads through contaminated food, water, or contact with an infected person.

By isolating the child, the risk of spreading the infection to family members is significantly reduced.

Choice C rationale:

Washing hands thoroughly with soap and water after handling the child's soiled items is a fundamental hygiene practice.

Proper handwashing removes bacteria and viruses from the hands, preventing the spread of infections.

Teaching the parents this measure ensures they do not inadvertently transfer the bacteria to surfaces or other people in the household.

Choice D rationale:

Sharing utensils and towels with the child is not an appropriate measure to prevent the spread of gastroenteritis.

This behavior increases the risk of cross-contamination and can lead to other family members becoming infected.

It is important to stress the importance of personal hygiene items to limit the spread of the disease.

Choice E rationale:

Disinfecting surfaces and toys that the child has come into contact with is crucial in preventing the spread of gastroenteritis.

The virus or bacteria causing the illness can survive on surfaces for a certain period, making it essential to regularly disinfect commonly touched items.

This measure reduces the risk of other family members coming into contact with the pathogens and getting sick.

Choice D rationale:

Administering antibiotics is appropriate for a child with bacterial gastroenteritis.

Bacterial gastroenteritis is caused by bacteria such as Salmonella or Escherichia coli, and antibiotics are prescribed to eliminate the bacteria from the body.

However, it is essential to note that not all cases of gastroenteritis require antibiotics.

Antibiotics are specifically used for bacterial infections and are not effective against viral gastroenteritis.

Choice A rationale:

Administering antiviral medication is not appropriate for bacterial gastroenteritis.

Antiviral medications are designed to treat viral infections, and bacterial gastroenteritis requires antibiotics to eliminate the bacteria causing the illness.

Choice B rationale:

Offering a clear liquid diet is a general measure used for both viral and bacterial gastroenteritis.

Clear liquids help prevent dehydration and provide essential electrolytes.

However, this intervention does not directly target the bacterial infection.

It is important to combine this with antibiotic therapy for bacterial gastroenteritis.

Choice C rationale:

Providing probiotics is generally beneficial for gut health but may not be the primary intervention for bacterial gastroenteritis.

Probiotics contain beneficial bacteria that can help restore the natural balance of the gut flora.

While probiotics can be useful in some cases, the primary treatment for bacterial gastroenteritis remains antibiotics to eliminate the harmful bacteria causing the infection.

Choice C rationale:

Probiotics promote the growth of beneficial bacteria in the gut.

In the context of gastroenteritis, probiotics can help restore the balance of the gut flora, especially after a course of antibiotics.

Beneficial bacteria aid in digestion and support the immune system.

By promoting the growth of these beneficial bacteria, probiotics contribute to the overall health of the gastrointestinal tract.

Choice A rationale:

"They help prevent the infection from spreading to others.”.

This statement is incorrect.

Probiotics do not prevent the spread of infections to others.

Instead, they focus on restoring the natural balance of bacteria in the gut.

Choice B rationale:

"Probiotics kill the bacteria causing gastroenteritis.”.

This statement is incorrect.

Probiotics do not have a direct bactericidal effect against the bacteria causing gastroenteritis.

They work by promoting the growth of beneficial bacteria rather than killing harmful bacteria.

Choice D rationale:

"Probiotics relieve the symptoms of gastroenteritis.”.

While probiotics can support overall gut health, saying they directly relieve symptoms might be an oversimplification.

Probiotics may help in reducing symptoms indirectly by restoring gut balance, but they might not provide immediate relief from symptoms like diarrhea or abdominal pain.

It's essential to manage symptoms with appropriate medical guidance and treatments.

Choice A rationale:

Thirst and dry mouth are common signs of dehydration in adults, but in pediatric patients, especially infants, the signs are different.

Children may not be able to communicate their thirst effectively, and dry mouth might not be as noticeable as other signs.

Choice B rationale:

Rapid heart rate and low blood pressure are symptoms of shock, which can occur in severe dehydration.

However, these symptoms are not specific to dehydration and can be present in other conditions.

Sunken eyes and fontanelle in infants are more specific indicators of dehydration in pediatric patients.

Sunken eyes occur due to loss of tissue turgor, and a sunken fontanelle (the soft spot on an infant's head) is a late sign of dehydration.

Choice D rationale:

Lethargy and irritability can be signs of dehydration, but they are nonspecific and can occur in various pediatric conditions.

Sunken eyes and fontanelle, on the other hand, are more specific to dehydration, especially in infants.

Choice A rationale:

Gastrointestinal illnesses, particularly diarrhea and vomiting, lead to fluid loss from the body.

Diarrhea can cause significant loss of water and electrolytes, leading to dehydration.

Vomiting, especially when persistent, can also result in fluid depletion.

These conditions are common causes of dehydration in both children and adults.

Choice B rationale:

Excessive sweating during physical activity or in hot weather can lead to dehydration in individuals, but this scenario does not apply to the child described in the question, who is experiencing decreased urine output and dark-colored urine.

Sweating excessively is more common in older children and adults during physical activities.

Choice C rationale:

Fever, which increases the body's fluid requirements, is a valid point.

However, the child in this scenario does not have fever mentioned as a symptom.

In the absence of fever, gastrointestinal illnesses are the more likely cause of dehydration.

Choice D rationale:

Certain medical conditions, such as diabetes or kidney disease, can lead to chronic dehydration.

However, these conditions are not mentioned in the scenario provided.

In the absence of information about underlying medical conditions, gastrointestinal illnesses remain the most likely cause of the child's dehydration.

Choice A rationale:

Thirst and dry mouth are early signs of dehydration.

When the body loses fluids, it signals the brain to increase thirst and conserve water.

Dry mouth can occur due to reduced saliva production when the body is dehydrated.

Choice B rationale:

Decreased urine output and dark-colored urine are indicators of concentrated urine, suggesting dehydration.

Reduced fluid intake or excessive fluid loss can lead to decreased urine production, and the urine becomes more concentrated, appearing darker than usual.

Choice C rationale:

Rapid heart rate and low blood pressure are signs of hypovolemic shock, a severe form of dehydration where the body cannot circulate enough blood to meet its needs.

This can happen in severe cases of dehydration when there is a significant loss of fluids and electrolytes.

Choice D rationale:

Poor skin turgor is a classic clinical sign of dehydration.

Skin turgor refers to the skin's ability to return to its normal position after being pinched.

In dehydrated individuals, the skin loses elasticity and remains tented or "pinched" after being pulled up.

This indicates a lack of fluid in the body.

Choice E rationale:

Increased energy and playfulness are not typical signs of dehydration.

Dehydrated children are more likely to be lethargic and irritable due to the physiological stress on their bodies.

Choice A rationale:

Vital signs are essential in assessing dehydration.

An elevated heart rate may indicate compensatory mechanisms due to decreased intravascular volume.

Low blood pressure may suggest severe dehydration, and abnormal temperature may indicate an underlying infection.

These parameters provide crucial information about the child's circulatory status, helping to assess the severity of dehydration.

Choice B rationale:

Physical examination findings, such as skin turgor and mucous membrane moisture, are valuable indicators of dehydration.

Poor skin turgor, where the skin doesn't return to its normal position promptly when pinched, indicates decreased tissue turgor due to fluid loss.

Dry mucous membranes, including the mouth, suggest dehydration and help evaluate the extent of fluid deficit.

These signs offer direct visual clues about the child's hydration status.

Choice C rationale:

Laboratory tests play a significant role in diagnosing dehydration.

A complete blood count (CBC) helps identify elevated hematocrit levels, indicating hemoconcentration due to fluid loss.

Electrolyte levels, specifically sodium and potassium, provide insights into the child's electrolyte balance, which can be disrupted in dehydration.

Urine specific gravity measures the kidney's ability to concentrate urine; a high specific gravity suggests concentrated urine due to reduced fluid intake.

These tests aid in confirming the diagnosis and assessing the severity of dehydration.

Choice D rationale:

Assessing the child's history is fundamental in understanding the underlying cause of dehydration.

Recent fluid intake and urine output patterns help determine the balance between intake and output.

Symptoms such as diarrhea, vomiting, and fever indicate potential causes of fluid loss.

Additionally, evaluating the child's overall health and any recent illnesses provides context for the dehydration, guiding appropriate treatment.

Choice A rationale:

Gastrointestinal illnesses, including diarrhea and vomiting, lead to fluid loss, significantly contributing to dehydration in children.

Diarrhea increases water and electrolyte loss from the body, while vomiting leads to rapid fluid depletion.

These conditions can be severe, especially in infants and young children, making them prone to dehydration.

Choice B rationale:

Excessive sweating during physical activity or in hot weather can result in significant fluid loss.

Children, especially when engaged in vigorous activities, can sweat profusely, leading to dehydration, especially if fluid intake does not match the loss.

Monitoring fluid balance is crucial during such situations to prevent dehydration-related complications.

Choice C rationale:

Insufficient fluid intake due to poor feeding or decreased thirst perception can lead to dehydration, especially in infants and young children who rely heavily on fluid intake for their hydration needs.

Children may not recognize their thirst or may refuse to drink due to illness, leading to decreased fluid intake.

This can result in dehydration, emphasizing the importance of assessing feeding habits and fluid intake patterns.

Choice D rationale:

Sunken eyes and fontanelle in infants are physical signs of dehydration, not etiological factors.

Sunken eyes are due to decreased tissue turgor, indicating dehydration.

Fontanelle, the soft spot on an infant's head, can appear sunken in dehydration.

These signs are crucial in assessing the severity of dehydration during physical examination but do not contribute to the causes of dehydration.

Choice A rationale:

"The child's favorite foods and beverages" are not relevant when assessing dehydration.

While dietary habits are essential for overall health, they do not provide information about the child's hydration status.

Choice B rationale:

"The child's school attendance and activities" are unrelated to the assessment of dehydration.

School attendance and activities are important for a child's social and educational development but do not provide any insight into the child's fluid balance or hydration status.

Choice C rationale:

"The child's skin turgor and mucous membranes" are crucial indicators of dehydration during physical examination.

Poor skin turgor, where the skin tents or remains elevated after being pinched, suggests decreased tissue elasticity due to fluid loss.

Dry mucous membranes, including the mouth, indicate dehydration.

These signs provide immediate visual clues about the child's hydration status and guide further assessment and intervention.

Choice D rationale:

"The child's vaccination history" is not relevant to the assessment of dehydration.

While vaccination history is essential for preventive healthcare, it does not provide any information about the child's current hydration status or fluid balance.

Choice A rationale:

Maintaining a warm room temperature is not the key to preventing dehydration.

Dehydration occurs when the body loses more fluids than it takes in, and temperature control in the room doesn't directly address this issue.

Choice B rationale:

The significance of oral rehydration solution (ORS) is a crucial factor in preventing and treating dehydration.

ORS contains a balanced mixture of salts and sugars that help the body reabsorb water and electrolytes lost due to dehydration.

It is the most effective way to rehydrate a dehydrated child.

Educating the client about the importance of ORS is essential because it provides a clear solution to the problem of dehydration.

Choice C rationale:

The need for a complete blood count (CBC) testing is unrelated to the prevention of dehydration.

CBC is a diagnostic test used to assess various blood parameters, including red and white blood cell counts.

It is not a preventive measure against dehydration.

Choice D rationale:

Suggesting the child's need for frequent, heavy meals is not an appropriate way to prevent dehydration.

In fact, heavy meals can sometimes worsen dehydration as they may be difficult to digest, leading to an increased risk of vomiting and diarrhea, which exacerbate fluid loss.

Choice A rationale:

Administering oral rehydration solution (ORS) is a crucial nursing intervention for a dehydrated child.

ORS helps replenish the lost fluids and electrolytes, making it an effective treatment for dehydration.

Choice B rationale:

Keeping the child in a cold environment is not an appropriate intervention for a dehydrated child.

Dehydration is not related to room temperature, and maintaining a comfortable environment is important, but extreme cold could cause discomfort to the child.

Choice C rationale:

Monitoring the child's vital signs is an essential nursing intervention when caring for a dehydrated child.

Vital signs, including heart rate, respiratory rate, blood pressure, and temperature, can provide important information about the child's condition and hydration status.

Regular monitoring helps in assessing the child's progress and identifying any worsening symptoms.

Choice D rationale:

Providing heavy meals at regular intervals is not an appropriate intervention for a dehydrated child.

As mentioned earlier, heavy meals can be difficult to digest and may worsen dehydration.

It is more important to focus on rehydration with fluids like ORS.

Choice E rationale:

Educating the child and caregivers about dehydration is an important nursing intervention.

Teaching them about the signs and symptoms of dehydration, the importance of ORS, and how to prevent it in the future is essential for the child's well-being and for preventing future episodes of dehydration.

Choice A rationale:

Lethargy and muscle weakness are common signs of electrolyte imbalances in a dehydrated child.

Dehydration can lead to an imbalance of electrolytes, such as sodium and potassium, which affects muscle function and overall energy levels.

Choice B rationale:

Increased appetite and hyperactivity are not typical signs of electrolyte imbalances in a dehydrated child.

Dehydration often leads to a decreased appetite and lethargy.

Choice C rationale:

Shortness of breath and coughing are not directly related to electrolyte imbalances in a dehydrated child.

These symptoms are more likely to be associated with respiratory or pulmonary issues rather than dehydration.

Choice D rationale:

Excessive thirst and urination are common signs of dehydration but are not indicative of electrolyte imbalances.

These symptoms occur as the body attempts to compensate for fluid loss by increasing thirst and increasing urine output.

Electrolyte imbalances are more likely to manifest as muscle weakness and cardiac arrhythmias.

Choice A rationale:

"Height and weight.”.

Rationale: While monitoring height and weight is important for a child's growth and development, these parameters are not the primary vital signs to assess dehydration.

Dehydration assessment focuses on immediate physiological indicators, such as heart rate and blood pressure.

Choice B rationale:

"Heart rate and blood pressure.”.

Rationale: This is The correct answer.

When assessing a dehydrated child, monitoring vital signs such as heart rate and blood pressure is crucial.

Dehydration can lead to an increased heart rate and decreased blood pressure.

These parameters provide valuable information about the child's circulatory status and fluid balance.

Choice C rationale:

"Hair and eye color.”.

Rationale: Hair and eye color are not relevant parameters for assessing dehydration.

They are genetic traits and do not change in response to dehydration.

Choice D rationale:

"Shoe size and clothing size.”.

Rationale: Shoe size and clothing size are not relevant for assessing dehydration.

These measurements are related to a child's growth and body structure but do not provide information about their hydration status.

Choice A rationale:

Fluid deficit (in mL) = body weight (in kg) x 0.03.

Rationale: This calculation significantly underestimates the fluid deficit for a child with moderate dehydration.

Dehydration often requires more significant fluid replacement.

Choice B rationale:

Fluid deficit (in mL) = body weight (in kg) x 0.06.

Rationale: This calculation overestimates the fluid deficit for a child with moderate dehydration.

Using this formula would result in excessive fluid replacement, which can be harmful.

Choice C rationale:

Fluid deficit (in mL) = body weight (in kg) x 0.1.

Rationale: This calculation overestimates the fluid deficit for a child with moderate dehydration.

Using this formula would result in excessive fluid replacement, which can be harmful.

Choice D rationale:

Fluid deficit (in mL) = body weight (in kg) x 0.04.

Rationale: This is The correct answer.

The appropriate fluid deficit calculation for a child who weighs 12 kg with moderate dehydration is to multiply their body weight by 0.04.

For this child, it would be 12 kg x 0.04 = 480 mL.

This formula is a commonly used guideline to estimate fluid deficit in cases of dehydration.

The correct answer is Choice B: Total maintenance fluids = 1200 mL/day.

Choice A rationale:

This value exceeds the calculated requirement for a child weighing 18 kg using the Holliday-Segar method.

Choice B rationale:

The Holliday-Segar method calculates maintenance fluids based on weight as follows:

• For the first 10 kg, the requirement is 100 mL/kg.
• For the next 10 kg, the requirement is 50 mL/kg.

Thus, for a child weighing 18 kg:

• First 10 kg: 10 kg x 100 mL/kg = 1000 mL
• Next 8 kg: 8 kg x 50 mL/kg = 400 mL Total maintenance fluid requirement = 1000 mL + 400 mL = 1400 mL/day.

So, actually, the correct answer should be Choice D: 1400 mL/day.

Choice C rationale:

This value is higher than the requirement for 18 kg based on the Holliday-Segar method.

Choice D rationale:

This is the correct calculation based on the method described above: 1000 mL for the first 10 kg plus 400 mL for the next 8 kg totals 1400 mL/day.

“Severe dehydration, which is ≥10% loss of body weight.”.

Choice A rationale:

Mild dehydration is typically classified as a 3-5% loss of body weight.

The signs and symptoms described in the scenario, such as dry mucous membranes, decreased urine output, and decreased skin turgor, are indicative of more severe dehydration than a 3-5% loss.

Choice B rationale:

Moderate dehydration is generally considered to be a 6-9% loss of body weight.

However, the signs and symptoms presented in the scenario suggest a more severe state of dehydration.

Choice C rationale:

Severe dehydration is classified as a loss of ≥10% of body weight.

The signs and symptoms observed by the nurse, including dry mucous membranes, decreased urine output, and decreased skin turgor, are consistent with severe dehydration, making choice C The correct classification.

Choice D rationale:

No dehydration is defined as less than a 3% loss of body weight.

The clinical manifestations observed in the child, as described in the scenario, clearly indicate dehydration.

In this case, the child's signs and symptoms align with the classification of severe dehydration, which is characterized by a loss of ≥10% of body weight.

These symptoms include dry mucous membranes, decreased urine output, and decreased skin turgor.

It's crucial to recognize the severity of dehydration accurately to initiate the appropriate treatment and prevent complications.

“I understand that my child’s hydration status will be continuously assessed.”.

Choice A rationale:

While a child's age and weight may play a role in determining fluid replacement, this statement doesn't encompass the entire concept of managing dehydration.

Monitoring hydration status involves assessing clinical signs and symptoms, as well as ongoing evaluation.

Choice B rationale:

Electrolyte solutions and supplements are indeed part of the treatment for dehydration.

However, this statement doesn't reflect the comprehensive understanding of managing a dehydrated child, including continuous assessment of hydration status.

Choice C rationale:

This statement indicates a correct understanding.

Continuous assessment of a child's hydration status is essential in managing dehydration.

It allows healthcare providers to monitor the child's response to treatment and make necessary adjustments.

Choice D rationale:

Collaboration within the healthcare team is important, but this statement doesn't specifically address the understanding of fluid replacement and dehydration management.

The correct response is choice C because it highlights the critical aspect of continuous assessment, which is essential to ensure that the child's hydration status is being monitored effectively during treatment.

Choice A rationale:

Assessing the degree of dehydration based on clinical signs and symptoms is a fundamental step in managing a dehydrated child.

This assessment guides the choice of appropriate treatment and fluid replacement.

Choice B rationale:

Calculating the fluid deficit based on the degree of dehydration is crucial in determining the amount of fluid that needs to be replaced accurately.

This calculation helps prevent under or overhydration.

Choice D rationale:

Monitoring the child's response to treatment and adjusting the plan accordingly is essential.

Dehydration management is an ongoing process, and adjustments may be necessary based on how the child is progressing.

Choice E rationale:

Communication with physicians, nutritionists, and other healthcare professionals is vital for comprehensive care.

Dehydration management often involves a multidisciplinary approach to address the child's overall health and nutritional needs.

Selecting all of these options (A, B, D, and E) ensures a comprehensive approach to managing dehydration in a child.

It involves assessment, calculation, monitoring, and collaboration with healthcare professionals for the best outcome.

Choice A rationale:

Administer electrolyte solutions or supplements as prescribed by the physician.

Rationale: While administering electrolyte solutions or supplements may be part of the treatment plan for a dehydrated child, it is not the initial action that the nurse should take.

The first step should be to assess the child's condition and monitor their response to treatment.

Choice B rationale:

Monitor the child’s response to treatment and adjust the plan accordingly.

Rationale: This is The correct answer.

Dehydration is a complex condition, and the nurse's initial action should be to closely monitor the child's response to treatment, which may include oral or intravenous rehydration.

By monitoring the child's vital signs, urine output, and clinical signs, the nurse can make real-time adjustments to the treatment plan.

Choice C rationale:

Collaborate with physicians, nutritionists, and other healthcare professionals to ensure comprehensive care.

Rationale: Collaboration with other healthcare professionals is important for the overall care of the child, but it is not the immediate action needed to correct electrolyte imbalances in a dehydrated child.

Monitoring and treatment adjustments come first.

Choice D rationale:

Assess the degree of dehydration based on clinical signs and symptoms.

Rationale: While assessing the degree of dehydration is important, it should not be the only action taken.

Monitoring the child's response to treatment and adjusting the plan is equally crucial.

Dehydration assessment is typically part of the initial evaluation, but ongoing monitoring is necessary to ensure the child's condition improves.

Choice A rationale:

Ensure appropriate fluid intake based on age and weight.

Rationale: This is an essential piece of advice to prevent dehydration in children.

Proper fluid intake based on age and weight helps maintain hydration.

However, it's not the only advice that should be given.

Choice B rationale:

Monitor for signs of dehydration such as dry mucous membranes and decreased urine output.

Rationale: Monitoring for signs of dehydration is crucial, but it's not the only preventive measure.

Detecting dehydration early is important for timely intervention, but proactive prevention is also necessary.

Choice C rationale:

Encourage consumption of electrolyte solutions during periods of illness.

Rationale: Encouraging the consumption of electrolyte solutions during illness is a valuable piece of advice, especially when children may lose fluids due to vomiting or diarrhea.

However, it's not the only preventive measure.

Choice D rationale:

All these measures are necessary to prevent dehydration in children.

Rationale: This is The correct answer.

Preventing dehydration in children involves a combination of measures, including ensuring appropriate fluid intake, monitoring for signs of dehydration, and encouraging electrolyte solutions during illness.

All these measures work together to keep a child well-hydrated and prevent dehydration.

Choice A rationale:

Normal saline (0.9% NaCl).

Rationale: Normal saline is the most appropriate choice for a client with dehydration and hyponatremia.

It provides a balanced solution with sodium and chloride, which can help correct hyponatremia and rehydrate the client.

It is an isotonic solution and is commonly used for fluid resuscitation.

Choice B rationale:

Half normal saline (0.45% NaCl).

Rationale: Half normal saline is also an isotonic solution, but it contains less sodium than normal saline.

In a case of hyponatremia, it's better to use a solution with a higher sodium concentration, making choice A (normal saline) more appropriate.

Choice C rationale:

Lactated Ringer’s.

Rationale: Lactated Ringer's is another isotonic solution, but it may not be the best choice for a client with hyponatremia.

It contains lactate, which can be metabolized to bicarbonate, potentially worsening the client's hyponatremia.

Therefore, it's not the most appropriate option in this case.

Choice D rationale:

D5W (5% dextrose in water).

Rationale: D5W is a hypotonic solution and should not be used for rehydration in a client with hyponatremia.

It can exacerbate the electrolyte imbalance and is not suitable for addressing dehydration.

Normal saline (0.9% NaCl).

Choice A rationale:

Normal saline (0.9% NaCl) is the most appropriate choice for a client with burns and hypovolemia.

This isotonic solution helps to restore intravascular volume and replace lost fluids.

It contains sodium chloride in a concentration similar to that of the body's extracellular fluid, making it effective for rehydration and replenishing electrolytes in hypovolemic patients.

Choice B rationale:

Half normal saline (0.45% NaCl) is a hypotonic solution with a lower sodium concentration than the body's extracellular fluid.

It is not the best choice for treating hypovolemia and burns because it may not effectively expand intravascular volume and may cause cellular swelling.

Choice C rationale:

Lactated Ringer's is an isotonic solution, but it contains additional electrolytes and lactate.

While it can be suitable for some fluid replacement needs, normal saline is preferred for burn patients because it has a simpler composition and is effective for volume resuscitation in cases of hypovolemia.

Choice D rationale:

D5W (5% dextrose in water) is a solution that primarily provides dextrose for energy, not suitable for hypovolemia and burns.

It can cause dilutional hyponatremia if used as the primary fluid in hypovolemic patients.

The correct answer is B. Shakiness.

Choice A: Increased capillary refill Capillary refill time (CRT) is a simple and quick test requiring minimal equipment or time to perform. Prolonged CRT is a ‘red flag’ feature, identifying children with increased risk of significant morbidity or mortality. A normal CRT should be between 2-3 seconds when applied centrally, such as to the sternum or the forehead. Therefore, increased capillary refill is not typically associated with hypoglycemia.

Choice B: Shakiness Shakiness, or tremors, are rhythmic shaking movements that most often happen in the hands, but can also occur in the arms, legs, head, vocal cords, and torso. Tremors can occur while a child is resting or active. Shakiness is a common symptom of hypoglycemia.

Choice C: Thirst While it’s true that excessive thirst can be a sign of diabetes, it’s a tricky one when the patient is a child. Young children often drink plenty of fluids when they are perfectly healthy. However, thirst is typically associated with hyperglycemia, not hypoglycemia.

Choice D: Decreased appetite Loss of appetite (anorexia) is a common symptom in children. Acute illness in childhood is often associated with transient loss of appetite. However, decreased appetite is not typically a direct symptom of hypoglycemia.

Normal saline (0.9% NaCl).

Choice A rationale:

Normal saline (0.9% NaCl) is the most appropriate choice for a client with cerebral edema.

This isotonic solution is commonly used to maintain intravascular volume and provides a neutral effect on fluid balance in the brain.

It does not introduce additional electrolytes that could potentially worsen cerebral edema.

Choice B rationale:

Half normal saline (0.45% NaCl) is not the best choice for cerebral edema because it is hypotonic and may lead to cellular swelling, potentially exacerbating the edema.

Choice C rationale:

Lactated Ringer's, while isotonic, contains additional electrolytes and lactate.

In the case of cerebral edema, it is safer to use a solution with a simpler composition like normal saline to avoid any potential complications related to electrolyte imbalances.

Choice D rationale:

D5W (5% dextrose in water) is not recommended for cerebral edema because it contains dextrose and may not adequately address the underlying issue of increased intracranial pressure associated with cerebral edema.

Choice A rationale:

Albumin (5% or 25%) Albumin is the most appropriate IV fluid for a client with hypoalbuminemia and shock.

Albumin is a colloid solution that helps to increase oncotic pressure, which can be decreased in conditions like hypoalbuminemia.

This increased oncotic pressure can help draw fluids back into the vascular space, improving intravascular volume and blood pressure.

Therefore, it is a suitable choice for a patient with shock.

The two concentrations mentioned, 5% and 25%, refer to the percentage of albumin in the solution, and the choice between them depends on the severity of the patient's condition and the desired effect.

The 5% solution is often used for volume expansion and to improve hemodynamics, while the 25% solution is used for rapid volume expansion.

Choice B rationale:

Dextrans (Dextran-40 or Dextran-70) Dextrans are another type of colloid solution, but they are not the best choice for this specific situation.

Dextrans are often used as volume expanders but are more commonly employed in conditions where there is no issue with albumin levels.

In this case, the primary concern is hypoalbuminemia, and using albumin-based solutions would be more appropriate.

Choice C rationale:

Gelatin (Gelofusine or Haemaccel) Gelatin-based solutions are also colloids and can be used for volume expansion.

However, they are not the best choice for a patient with hypoalbuminemia because they do not address the low albumin levels.

Albumin solutions are preferred in such cases to help restore oncotic pressure and improve intravascular volume.

Choice D rationale:

Plasma protein fraction (Plasmanate or Plasmasteril) Plasma protein fraction solutions, also known as human albumin, are similar to albumin solutions.

However, in this context, albumin solutions are more commonly used.

Plasma protein fraction solutions may be indicated in specific situations, but the primary choice for a patient with hypoalbuminemia and shock would be albumin-based solutions, as they are specifically designed to address albumin deficiencies.

Choice A rationale:

“This fluid will help to increase your sodium levels which are currently too low.”.

The nurse should explain to the client that they are receiving Normal Saline (0.9% NaCl) to increase their sodium levels.

This is The correct choice because Normal Saline is a hypertonic solution containing 154 mEq/L of sodium and 154 mEq/L of chloride.

It is used in cases of hyponatremia to raise sodium levels.

Sodium is an essential electrolyte, and low levels can lead to symptoms such as weakness, confusion, and muscle cramps.

Choice B rationale:

“This fluid will help to decrease your sodium levels which are currently too high.”.

Normal Saline is a hypertonic solution that would not be used to lower sodium levels, as it would have the opposite effect and further elevate sodium levels.

Choice C rationale:

“This fluid will help to increase your potassium levels which are currently too low.”.

It is not used to increase potassium levels, and potassium replacement would require a different solution, such as potassium chloride.

Choice D rationale:

“This fluid will help to decrease your potassium levels which are currently too high.”.

Normal Saline does not address high potassium levels; it is used to address hyponatremia and dehydration by increasing sodium levels.

Choice A rationale:

“This fluid will help to restore my sodium levels and replace the fluids I lost from vomiting.”.

The client should understand that they are receiving Half Normal Saline (0.45% NaCl) to restore sodium levels and replace lost fluids due to vomiting.

Half Normal Saline contains 77 mEq/L of sodium and 77 mEq/L of chloride, making it a suitable choice for a patient with mild hyponatremia and fluid loss from vomiting.

It helps restore sodium levels without the risk of overcorrection seen with 0.9% NaCl.

Choice B rationale:

“This fluid will help to lower my sodium levels and replace the fluids I lost from sweating.”.

Half Normal Saline is not used to lower sodium levels; its purpose is to restore sodium levels and provide fluids for cases like vomiting or other fluid losses.

Sweating typically leads to fluid loss, not sodium loss, and Half Normal Saline is not a treatment for high sodium levels.

Choice C rationale:

“This fluid will help to restore my potassium levels and replace the fluids I lost from vomiting.”.

Half Normal Saline does not address potassium levels, and the primary reason for using it is to address sodium imbalances and fluid loss, not potassium-related issues.

Choice D rationale:

“This fluid will help to lower my potassium levels and replace the fluids I lost from sweating.”.

Half Normal Saline is not used to lower potassium levels and is not specifically indicated for treating high potassium.

Additionally, it is not typically used to address fluid loss from sweating.

Choice A rationale:

Lactated Ringer's solution is not contraindicated in cases of hyperkalemia.

This solution contains potassium in a relatively low concentration of 4 mEq/L, which is unlikely to significantly impact hyperkalemia.

Choice B rationale:

Lactated Ringer's solution can be contraindicated in cases of hypokalemia.

While it does contain potassium, the concentration is relatively low at 4 mEq/L.

In cases of severe hypokalemia, a more potassium-rich solution might be preferred.

Choice C rationale:

Lactated Ringer's solution can be used in cases of lower GI fluid loss.

It can help replace lost fluids and electrolytes effectively.

Choice D rationale:

Lactated Ringer's solution can be used in cases of upper GI fluid loss.

It helps restore lost fluids and electrolytes.

Choice E rationale:

Lactated Ringer's solution is not contraindicated in cases of lactic acidosis.

In fact, it contains lactate (28 mEq/L), which can be metabolized to bicarbonate and help correct acidosis.

Choice A rationale:

The client's statement, "This IV fluid will provide me with hydration and calories," is correct.

D10W contains 10% dextrose and is used to provide both hydration and calories to the patient.

Choice B rationale:

D10W would not help lower blood sugar levels.

In fact, it would increase blood sugar levels due to the high concentration of dextrose.

Choice C rationale:

D10W does not provide essential electrolytes, so the statement is incorrect.

It's primarily used for calorie supplementation and hydration.

Choice D rationale:

D10W would not help increase blood pressure.

While it can provide hydration, it does not contain medications or components specifically intended to increase blood pressure.

Sunken fontanelle (in infants).

C. Dry mucous membranes.

E. Lethargy.

Choice A rationale:

Sunken fontanelle (in infants) is a clinical sign of dehydration.

The fontanelle is the soft spot on an infant's head, and when it becomes sunken, it suggests that the child is dehydrated.

This occurs because a lack of adequate fluid causes the brain to temporarily shrink, leading to the sunken appearance.

Choice B rationale:

Increased urine output is not typically a sign of dehydration.

In fact, dehydration often leads to decreased urine output as the body attempts to conserve fluid.

Increased urine output can be a sign of other conditions, such as diabetes.

Choice C rationale:

Dry mucous membranes are a classic sign of dehydration.

When the body lacks sufficient fluids, the mucous membranes in the mouth and other areas can become dry and sticky.

This is an important clinical indicator of dehydration.

Choice D rationale:

Normal skin turgor is not a sign of dehydration.

Skin turgor refers to the skin's ability to bounce back when pinched and released.

In a hydrated individual, the skin should have good turgor.

Dehydration can lead to poor skin turgor, but normal skin turgor does not indicate dehydration.

Choice E rationale:

Lethargy is a potential sign of dehydration.

When a child is dehydrated, they may become lethargic or unusually tired because their body is not receiving the necessary fluids to function properly.

Lethargy can be an early sign of dehydration in children.

Approximately 100 mL/hour.

To calculate the total hourly fluid replacement rate, we can use the Holliday-Segar method, which is commonly used in pediatrics.

According to this method, a child's daily maintenance fluid requirement is calculated as follows: For the first 10 kg of body weight: 100 mL/kg/day.

For the next 10 kg of body weight: 50 mL/kg/day.

For each additional kg of body weight: 20 mL/kg/day.

In this case, the child weighs 14 kg.

So, we calculate as follows: For the first 10 kg: 10 kg x 100 mL/kg/day = 1000 mL/day.

For the next 4 kg (14 kg - 10 kg): 4 kg x 50 mL/kg/day = 200 mL/day.

Now, add these two together: 1000 mL/day + 200 mL/day = 1200 mL/day.

To find the hourly rate, we divide the daily requirement by 24 (hours in a day): 1200 mL/day ÷ 24 hours/day = 50 mL/hour.

So, the child's total hourly fluid replacement rate should be approximately 50 mL/hour.

However, this is an approximate rate.

To be more conservative in the case of severe dehydration, it's common to round this up to approximately 100 mL/hour to ensure that the child receives adequate fluids to rehydrate.

Choice A rationale:

Approximately 58 mL/hour is not The correct answer.

This calculation does not match the standard Holliday-Segar method used in pediatrics for fluid replacement.

Choice B rationale:

Approximately 140 mL/hour is not The correct answer.

This calculation significantly exceeds the recommended hourly fluid replacement rate for a child of this weight, which could potentially lead to overhydration.

Choice D rationale:

Approximately 82 mL/hour is not The correct answer.

This calculation does not align with the standard method for calculating fluid replacement in pediatric patients.

Communicate with the healthcare team.

To ensure comprehensive care during the treatment and management of dehydration in children, communication with the healthcare team is essential.

Here's the rationale for this choice:

Choice A rationale:

Administer electrolyte solutions only.

This is not The correct approach.

While administering electrolyte solutions is a vital part of managing dehydration, it is not the only aspect of care.

Comprehensive care also includes assessing the child's overall condition, monitoring vital signs, and addressing any underlying causes of dehydration.

Choice B rationale:

Communicate with the healthcare team.

This is The correct answer.

Dehydration management often requires a multidisciplinary approach.

Communicating with the healthcare team, which may include physicians, dietitians, and other specialists, is crucial to ensure that the child receives appropriate treatment and that any underlying medical issues are addressed.

It also allows for coordinated care and adjustment of the treatment plan as needed.

Choice C rationale:

Rely solely on clinical signs to assess hydration status.

Relying solely on clinical signs is not sufficient for comprehensive care.

While clinical signs are important indicators of hydration status, laboratory tests and monitoring are also necessary to accurately assess and manage dehydration.

Choice D rationale:

Skip monitoring the child's response to treatment.

Skipping monitoring is not advisable.

Monitoring the child's response to treatment is a critical part of dehydration management.

It helps ensure that the child is improving, and adjustments can be made to the treatment plan if necessary.

Choice A rationale:

Allergies in children are not primarily caused by bacterial infections.

While infections can certainly exacerbate allergy symptoms, they are not the primary cause of allergies in children.

Allergies are more related to immune responses to specific substances.

Choice B rationale:

Common allergens for children do not typically include cigarette smoke and exercise.

Cigarette smoke can exacerbate respiratory issues and trigger symptoms in children with allergies or asthma, but it is not an allergen itself.

Exercise is generally a healthy activity for children and is not considered an allergen.

Choice D rationale:

Allergies in children are not solely caused by exposure to pet dander.

While pet dander can be a significant allergen for some children, allergies in children are typically triggered by a wide range of allergens, including pollen, dust mites, certain foods, and more.

Choice C rationale:

The correct answer is C.

Allergies in children can be influenced by genetic factors, environmental exposures, and immune system dysregulation.

Genetic predisposition can make a child more susceptible to allergies.

Environmental exposures to allergens can trigger allergic reactions, and immune system dysregulation can contribute to the development of allergies.

Choice A rationale:

Asthma is not characterized by a lack of airway sensitivity and hyperresponsiveness.

In fact, asthma is often associated with increased airway sensitivity and hyperresponsiveness.

This heightened reactivity of the airways is a hallmark of asthma.

Choice B rationale:

In asthma, airway muscles do not relax and widen during an episode.

Instead, they constrict or tighten, leading to airway obstruction and making breathing more difficult.

This bronchoconstriction is a key feature of asthma.

Choice D rationale:

Exposure to allergens or irritants in asthma does have an impact on airway constriction.

In individuals with asthma, exposure to allergens or irritants can trigger an inflammatory response in the airways, leading to increased bronchoconstriction and worsening symptoms.

Choice C rationale:

The correct answer is C.

Chronic inflammation of the airways in asthma does lead to increased airway sensitivity and hyperresponsiveness.

This chronic inflammation makes the airways more reactive to various triggers, including allergens, and contributes to the characteristic symptoms of asthma.

Choice B rationale:

While exercise is generally beneficial for children, it can trigger asthma symptoms in some individuals, especially if they have exercise-induced bronchoconstriction.

However, the primary focus should be on managing and controlling asthma symptoms during exercise rather than discouraging physical activity.

The other options are more directly related to managing allergies and asthma.

Choice E rationale:

Administering antibiotics regularly to prevent asthma exacerbations is not a recommended intervention.

Antibiotics are used to treat bacterial infections, not to prevent asthma exacerbations.

In fact, overuse of antibiotics can lead to antibiotic resistance and should be avoided unless there is a specific medical indication.

Choice A rationale:

The correct answer is A.

Providing a smoke-free environment at home is essential for managing allergies and asthma in children.

Secondhand smoke can exacerbate respiratory symptoms and increase the risk of asthma attacks.

Eliminating exposure to smoke is a crucial step in managing these conditions.

Choice C rationale:

The correct answer is C.

Identifying and avoiding allergens that trigger symptoms is a key component of managing allergies and asthma in children.

By minimizing exposure to known allergens, individuals can reduce the frequency and severity of allergic and asthmatic reactions.

Choice D rationale:

The correct answer is D.

Promoting good hand hygiene to prevent allergies is important, especially for reducing the risk of infections that could exacerbate allergy symptoms or asthma.

Proper hand hygiene can help prevent the spread of illnesses and reduce the likelihood of respiratory infections.

Choice A rationale:

Exposure to allergens and respiratory infections are common triggers for asthma symptoms in children.

Allergens, such as pollen, dust mites, and pet dander, can trigger allergic reactions in the airways, leading to asthma symptoms.

Respiratory infections, like the common cold or flu, can exacerbate asthma by causing airway inflammation and increased mucus production.

These triggers can lead to bronchoconstriction and worsen asthma symptoms in children.

Choice B rationale:

Consumption of certain foods and insect venom is not a common trigger for asthma symptoms in children.

While food allergies can lead to allergic reactions, they typically manifest as gastrointestinal or skin symptoms rather than respiratory issues.

Insect venom may cause anaphylactic reactions but is not a common cause of asthma symptoms.

Choice C rationale:

Playing outdoors and engaging in physical activities are not common triggers for asthma symptoms in children.

Physical activity can induce exercise-induced bronchoconstriction in some children with asthma, but this is different from the common triggers mentioned in choice A.

Being active is essential for overall health, and children with asthma can participate in sports with appropriate management.

Choice D rationale:

Exposure to excessive sunlight and hot weather is not a common trigger for asthma symptoms in children.

Asthma symptoms are typically worsened by cold, dry air, which can lead to airway constriction.

Hot weather and sunlight do not directly contribute to asthma exacerbations.

Choice A rationale:

IgE antibodies play a significant role in allergic reactions.

They are not insignificant.

IgE antibodies are specifically designed to recognize and bind to allergens, and when they do so, they trigger an immune response that includes the release of histamine and other inflammatory mediators.

These substances are responsible for the symptoms of allergies, such as itching, redness, and swelling.

Choice B rationale:

IgE antibodies do not inhibit the release of histamine in response to allergens; rather, they facilitate it.

The role of IgE antibodies is to promote the allergic response, leading to the release of histamine and other inflammatory molecules.

Choice D rationale:

IgE antibodies are not limited to respiratory infections.

While they are involved in the immune response against infections, they are primarily associated with allergic reactions.

IgE antibodies do not play a role exclusively in respiratory infections but are a key component in the allergic response.

Choice A rationale:

A high-pitched whistling sound when breathing is not a common symptom of allergic rhinitis in children.

This sound, known as wheezing, is more characteristic of asthma and bronchoconstriction.

Choice B rationale:

Difficulty breathing and chest tightness are not typical symptoms of allergic rhinitis but are more closely associated with asthma.

Allergic rhinitis primarily involves symptoms such as sneezing, nasal congestion, and itchy or watery eyes.

Choice D rationale:

A persistent cough, especially at night, is not a classic symptom of allergic rhinitis in children.

Instead, it is more often associated with conditions like postnasal drip or nighttime asthma symptoms.

The child's skin shows dryness, itching, and rash.

Choice A rationale:

"The child exhibits wheezing and coughing.”.

Wheezing and coughing are typical symptoms of respiratory issues like asthma but not necessarily associated with dry, itchy skin and redness, which are dermatological symptoms.

Therefore, this choice is not the likely manifestation.

Choice B rationale:

"The child has nasal congestion and itchy eyes.”.

Nasal congestion and itchy eyes are more indicative of allergic rhinitis or hay fever, not dry, itchy skin and redness.

This choice does not align with the presenting symptoms and is not the likely manifestation.

Choice D rationale:

"The child experiences difficulty breathing and chest tightness.”.

Difficulty breathing and chest tightness are more characteristic of asthma, but these symptoms primarily relate to the respiratory system.

The primary manifestation described in the question is related to the skin.

Therefore, this choice is not the likely manifestation.

Choice C rationale:

"The child's skin shows dryness, itching, and rash.”.

This choice is The correct answer.

The symptoms of dry, itchy skin and redness are typical signs of a skin condition, such as eczema or contact dermatitis.

The nurse is likely to observe these dermatological symptoms in the child.

Dryness, itching, and rash are often associated with skin conditions, and they are distinct from respiratory symptoms like coughing and wheezing.

Choice A rationale:

"Measure specific IgE antibodies in blood.”.

Measuring specific IgE antibodies in blood is a diagnostic test to identify allergies, but it is not directly related to assessing asthma symptoms in children.

This choice does not align with the question's focus on determining asthma symptoms.

Choice B rationale:

"Evaluate lung function using spirometry.”.

Spirometry is a crucial diagnostic tool for assessing lung function and is highly relevant for determining asthma symptoms in children.

It allows for the measurement of lung volume and airflow, making it an appropriate choice for evaluating asthma.

Choice C rationale:

"Assess for recurrent cough, especially at night.”.

Recurrent cough, especially at night, is a common symptom in children with asthma.

It is related to the narrowing of the airways and increased mucus production, making this choice appropriate for assessing asthma symptoms.

Choice D rationale:

"Monitor peak flow meter measurements.”.

Peak flow meter measurements are used to monitor lung function and are essential for managing asthma.

It helps assess the severity of asthma and the effectiveness of treatment.

Therefore, it is an appropriate choice for evaluating asthma symptoms.

Choice E rationale:

"Perform skin prick tests to identify allergens.”.

Skin prick tests are used to identify specific allergens, which can be useful in diagnosing allergies, but they are not directly related to assessing asthma symptoms.

Asthma assessment focuses more on lung function and respiratory symptoms.

"Perform a skin prick test.”.

Choice A rationale:

"Perform a skin prick test.”.

A skin prick test, also known as a skin allergy test, is a common method used to identify specific allergens in both children and adults.

It involves applying small amounts of allergens to the skin and observing for any allergic reactions, such as redness and swelling at the test sites.

This is a valuable diagnostic method to pinpoint the allergens triggering allergic reactions.

Choice B rationale:

"Conduct a spirometry test.”.

Spirometry is a lung function test and is not used to identify specific allergens.

It measures lung volume and airflow, making it more suitable for assessing respiratory conditions like asthma.

Choice C rationale:

"Administer a peak flow meter measurement.”.

Peak flow meter measurements are used to monitor lung function and asthma symptoms but do not identify specific allergens.

This choice is not relevant to the task of identifying allergens.

Choice D rationale:

"Measure specific IgE antibodies in blood.”.

Measuring specific IgE antibodies in the blood can help determine if a person has allergies, but it does not identify the specific allergens causing the allergies.

This test is valuable for confirming the presence of allergies but not for pinpointing allergens.