Nokea
A three-year-old is brought into the emergency department in her mother's arms. The child's mouth is open and she is drooling and lethargic. Her mother states that she became ill suddenly within the past 2 hours. What should the nurse do first?
- A. Draw blood cultures for complete blood count.
- B. Start an intravenous line.
- C. Inspect the child's throat with a tongue blade.
- D. Maintain the child in an undisturbed, upright position.
Correct Answer: D
Rationale: The symptoms suggest possible epiglottitis, a medical emergency. Maintaining the child in an undisturbed, upright position prevents airway obstruction and is the priority action.
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When preparing the teaching plan for the mother of a child with asthma, which of the following should the nurse include as signs to alert the mother that her child is having an asthma attack?
- A. Secretion of thin, copious mucus.
- B. Tight, productive cough.
- C. Wheezing on expiration.
- D. Temperature of 99.4°F (37.4°C).
Correct Answer: C
Rationale: Wheezing on expiration is a hallmark sign of an asthma attack, indicating airway narrowing. The mother should be taught to recognize this to initiate prompt treatment.
A child with a brain tumor is less responsive to verbal commands than he was when assessed the previous hour. The nurse should next:
- A. Raise the head of the bed.
- B. Notify the physician.
- C. Administer an analgesic.
- D. Obtain an oximeter reading.
Correct Answer: B
Rationale: Decreased responsiveness indicates worsening neurological status, requiring immediate physician notification for further evaluation.
The nurse identifies a nursing diagnosis of Risk for perioperative-positioning injury related to the surgical procedure for a school-age child scheduled for a tonsillectomy. Which of the following is an expected outcome for this nursing diagnosis?
- A. The child is able to tell about the surgery and recovery.
- B. The child remains on nothing-by-mouth (NPO) status for the designated preoperative period.
- C. The child and family demonstrate an understanding of the procedure.
- D. The child knows the parents will not leave.
Correct Answer: B
Rationale: The most appropriate outcome for a nursing diagnosis of Risk for perioperative-positioning injury related to the surgical procedure should be that the child remains NPO for the designated period of time before surgery, thereby minimizing the risk of aspiration during the surgery. Ability to tell about the surgery and demonstrating an understanding of the procedure are appropriate outcomes for a nursing diagnosis of Deficient knowledge. Knowing that the parents will not leave is associated with a nursing diagnosis of Anxiety or Fear related to separation from support systems or an unfamiliar environment.
As part of a health education program, the nurse teaches a group of parents CPR. The nurse determines the teaching has been effective when a parent states:
- A. If I am by myself, I should call for help before starting CPR.
- B. I should compress the chest using 2-3 fingers.
- C. I should deliver chest compression at a rate of 100 per minute.
- D. If I can't get the breaths to make the chest rise, I should administer abdominal thrusts.
Correct Answer: A
Rationale: Calling for help before starting CPR when alone ensures timely emergency response, which is critical for improving outcomes.
Parents bring their child to the emergency department because the child has stopped breathing. A nurse obtains a brief history of events occurring before and after the parents found the infant not breathing. Which of the following questions should the nurse ask the parents first?
- A. Was the infant sleeping while wrapped in a blanket?
- B. Was the infant lying on his stomach?
- C. What did the infant look like when you found him?
- D. When had you last checked on the infant?
Correct Answer: B
Rationale: Asking if the infant was lying on his stomach is critical, as prone sleeping is a major risk factor for SIDS and could explain the cessation of breathing.