Nokea
The nurse is caring for a 4-year-old child diagnosed with H. influenzae type B. Which signs and symptoms exhibited by the child would alert the nurse to suspect epiglottitis? (Select all that apply.)
- A. Harsh cough
- B. Restlessness
- C. Edematous epiglottis
- D. Child insists on lying down
- E. Drooling
Correct Answer: B,C,E
Rationale: The child with epiglottitis insists on sitting up, leans forward with the mouth open, and drools saliva because of the difficulty in swallowing.
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The nurse is caring for a toddler with acute laryngotracheobronchitis. Which assessment finding would indicate the child is experiencing increased respiratory obstruction?
- A. Restlessness
- B. Tachycardia
- C. Brassy cough
- D. Expiratory wheezing
Correct Answer: A
Rationale: Restlessness is a primary sign of increased respiratory obstruction.
The nurse offers a variety of fluids to a 5-year-old asthmatic child to compensate for the fluid loss through dyspnea. Which fluids are most appropriate?
- A. Room temperature water
- B. Carbonated beverages
- C. Iced fruit juice
- D. Cold milk
Correct Answer: A
Rationale: Room temperature fluids are the best. Carbonated and iced beverages increase spasm.
What will the nurse tell parents of a child with a positive throat culture for group A hemolytic streptococcus that the treatment is most likely to be?
- A. Acetaminophen and plenty of fluids
- B. Oral penicillin for 10 days
- C. Penicillin until his sore throat is gone
- D. Streptococcus immunization
Correct Answer: B
Rationale: When a throat culture is positive for group A beta-hemolytic streptococcus, penicillin is administered for 10 days even if symptoms are alleviated before the medication is finished.
After the 3-month-old child with respiratory syncytial virus is given a protocol of antiviral medications, the nurse explains that routine immunizations will need to be delayed for __ months.
Correct Answer: 9
Rationale: Antiviral medications for RSV can interfere with the immune response to vaccinations, requiring a 9-month delay.
A toddler must maintain bed rest for the diagnosis of pneumonia. What actions will the nurse implement? (Select all that apply.)
- A. Maintain strict bed rest.
- B. Consider age.
- C. Assess developmental level.
- D. Implement light play activities.
- E. Provide hypnotic medication as ordered.
Correct Answer: B,C,D
Rationale: Confinement to bed for a child does not always result in physical rest. In pediatrics, 'bed rest' means providing play therapy that promotes minimal activity.