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When caring for a child diagnosed with bronchiolitis, what is the priority nursing intervention?
- A. Administering bronchodilators
- B. Providing respiratory therapy
- C. Monitoring oxygen saturation
- D. Encouraging fluid intake
Correct Answer: B
Rationale: The priority nursing intervention for a child with bronchiolitis is providing respiratory therapy. This intervention aims to maintain airway patency, optimize oxygenation, and support effective breathing. Administering bronchodilators, though important, may not be the initial priority as respiratory therapy takes precedence in ensuring adequate oxygenation and ventilation. Monitoring oxygen saturation is crucial but is usually part of the ongoing assessment following the initiation of respiratory therapy. Encouraging fluid intake is essential for hydration but is not the priority intervention when addressing the respiratory distress associated with bronchiolitis.
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At 7 AM, a healthcare professional receives the information that an adolescent with diabetes has a 6:30 AM fasting blood glucose level of 180 mg/dL. What is the priority nursing action at this time?
- A. Encourage the adolescent to start exercising.
- B. Ask the adolescent to obtain an immediate glucometer reading.
- C. Inform the adolescent that a complex carbohydrate such as cheese should be eaten.
- D. Tell the adolescent that the prescribed dose of rapid-acting insulin should be administered.
Correct Answer: D
Rationale: The correct priority nursing action in this situation is to administer the prescribed dose of rapid-acting insulin. Rapid-acting insulin is necessary to help lower the elevated blood glucose level quickly, thereby preventing potential complications of hyperglycemia. Encouraging exercise, obtaining a glucometer reading, or suggesting consumption of complex carbohydrates like cheese may not address the immediate need to bring down the high blood glucose level effectively. Exercise could potentially raise blood glucose levels, obtaining a glucometer reading may delay necessary treatment, and consuming complex carbohydrates can further elevate blood glucose levels in this scenario.
When picked up by a parent or the nurse, an 8-month-old infant screams and seems to be in pain. After observing this behavior, what should the nurse discuss with the parent?
- A. Accidents and the importance of preventing them
- B. Limiting the infant's playtime with other children in the family
- C. Any other behaviors that the parent may have noticed
- D. Nutrition and specific vitamins recommended for infants
Correct Answer: C
Rationale: Discussing any other observed behaviors with the parent is important to identify patterns or potential issues that could be affecting the infant's well-being. By exploring additional behaviors, the nurse can gather more information to assess the infant comprehensively. This approach allows for a more holistic understanding of the infant's health status, rather than focusing solely on the observed behavior of screaming and apparent pain. Options A, B, and D are incorrect as they do not directly address the need to explore other behaviors that may provide insights into the infant's condition and well-being.
A 3-year-old child has a sudden onset of respiratory distress. The mother denies any recent illnesses or fever. You should suspect
- A. croup
- B. epiglottitis
- C. lower respiratory infection
- D. foreign body airway obstruction
Correct Answer: D
Rationale: In a 3-year-old child presenting with sudden respiratory distress without fever or recent illness, the most likely cause is a foreign body airway obstruction. Foreign body airway obstruction can lead to a sudden onset of respiratory distress as it blocks the air passage. Croup typically presents with a barking cough and stridor, often preceded by a viral illness. Epiglottitis is characterized by high fever, drooling, and a muffled voice. Lower respiratory infections usually present with symptoms such as cough, fever, and chest congestion. Therefore, in this case, the absence of recent illness or fever makes foreign body airway obstruction the most likely cause of the respiratory distress.
You are managing a 10-month-old infant who has had severe diarrhea and vomiting for 3 days and is now showing signs of shock. You have initiated supplemental oxygen therapy and elevated the lower extremities. En route to the hospital, you note that the child's work of breathing has increased. What must you do first?
- A. Lower the extremities and reassess the child
- B. Begin positive pressure ventilations and reassess the child
- C. Place a nasopharyngeal airway and increase the oxygen flow
- D. Listen to the lungs with a stethoscope for abnormal breath sounds
Correct Answer: A
Rationale: In this scenario, the infant is showing signs of shock with increased work of breathing. Lowering the extremities helps improve venous return to the heart, cardiac output, and oxygenation by reducing the pressure on the diaphragm. This action can alleviate the respiratory distress and is a critical step to take in a child with signs of shock. Beginning positive pressure ventilations (Choice B) should be considered if the infant's respiratory distress worsens despite lowering the extremities. Placing a nasopharyngeal airway and increasing oxygen flow (Choice C) may not directly address the increased work of breathing or the underlying shock condition. Listening to the lungs with a stethoscope (Choice D) may provide information on lung sounds but does not address the immediate need to improve breathing in a child with signs of shock.
A major developmental milestone of a toddler is the achievement of autonomy. What should the parents do to enhance their toddler's need for autonomy?
- A. Teach the child to share with others.
- B. Help the child learn society's roles.
- C. Teach the child to accept external limits.
- D. Help the child develop internal controls.
Correct Answer: D
Rationale: Toddlers striving for autonomy need to develop internal controls to foster their independence. Teaching the child to share (Choice A) focuses more on social skills rather than autonomy. Helping the child learn society's roles (Choice B) is important but not directly related to enhancing autonomy. Teaching the child to accept external limits (Choice C) is contrary to promoting autonomy as it emphasizes conformity to external rules rather than internal self-regulation.