Nokea
Which of the following findings is a clinical manifestation associated with this diagnosis?
- A. Tachypnea
- B. Tremors
- C. Increased appetite
- D. Bradycardia
Correct Answer: A
Rationale: The correct answer is A: Tachypnea. Tachypnea refers to rapid breathing, which is a common clinical manifestation associated with various medical conditions, including respiratory distress. In this particular diagnosis, tachypnea may indicate underlying respiratory issues or distress. Tremors (B) and increased appetite (C) are not typically associated with this diagnosis. Bradycardia (D), which is a slow heart rate, is also not a common clinical manifestation in this context.
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Which of the following information should the nurse include in the teaching?
- A. Place an infant who is 5 months old in a high chair to feed.
- B. Position a 1-month-old infant supine on a soft mattress.
- C. Provide an infant with a one-piece pacifier for non-nutritive sucking.
- D. Secure the infant's car seat behind an airbag.
Correct Answer: C
Rationale: The correct answer is C because providing an infant with a one-piece pacifier for non-nutritive sucking reduces the risk of choking and aspiration compared to multi-piece pacifiers. This information is crucial for infant safety during feeding. Choice A is incorrect as a 5-month-old infant should be seated in a high chair only if they can sit upright without support to prevent falls. Choice B is incorrect as placing a 1-month-old infant supine on a soft mattress increases the risk of sudden infant death syndrome (SIDS). Choice D is incorrect as securing an infant's car seat behind an airbag can be dangerous due to the risk of injury from the airbag deployment.
Which of the following safety measures should the nurse include in the teaching?
- A. Check clothing for loose buttons.
- B. Adjust the water heater temperature to 54° C (129.2° F).
- C. Place screens on all windows.
- D. Provide balloons for play.
Correct Answer: A
Rationale: The correct answer is A: Check clothing for loose buttons. This safety measure is important to prevent choking hazards in children. Loose buttons can easily come off and be swallowed. B is incorrect as the recommended water heater temperature is 49°C (120°F) to prevent scalding. C is irrelevant to the safety of a child's clothing. D is incorrect as balloons pose a choking hazard.
Which of the following actions should the nurse take first?
- A. Observe the child's throat with a flashlight.
- B. Give the child small sips of water.
- C. Administer an analgesic.
- D. Offer the child an ice collar.
Correct Answer: A
Rationale: The correct answer is A: Observe the child's throat with a flashlight. This is the first action the nurse should take as it helps assess for any signs of inflammation, infection, or obstruction in the throat, which could be causing the child's symptoms. By observing the throat, the nurse can gather important information to guide further interventions.
Choice B: Giving the child small sips of water can be important but should come after assessing the throat to ensure it is safe to swallow. Choice C: Administering an analgesic should be based on the assessment findings, not the first action. Choice D: Offering an ice collar is not indicated until the cause of the symptoms is identified.
Specify what condition the client is most likely experiencing.
- A. Pyloric stenosis
- C. Congestive heart failure
- D. Respiratory syncytial virus bronchiolitis
Correct Answer: C
Rationale: The correct answer is C: Congestive heart failure. The client is most likely experiencing Congestive heart failure due to presenting symptoms such as dyspnea, fatigue, edema, and possibly crackles on lung auscultation. These symptoms are indicative of fluid accumulation in the lungs and peripheral tissues, common in congestive heart failure. Pyloric stenosis (A) is a gastrointestinal condition, not related to the symptoms described. Respiratory syncytial virus bronchiolitis (D) typically presents with respiratory distress in infants. The other choices are omitted as they are not relevant to the symptoms described.
Which of the following actions should the nurse take first?
- A. Obtain an x-ray of the child's neck.
- B. Administer intravenous antibiotics.
- C. Initiate droplet precautions.
- D. Place intubation equipment at the bedside.
Correct Answer: D
Rationale: The correct action for the nurse to take first is to place intubation equipment at the bedside (Choice D). This is crucial in case the child's condition deteriorates rapidly and respiratory support is needed. Placing the intubation equipment ensures immediate access to airway management, which takes precedence over other actions. Obtaining an x-ray may provide diagnostic information but is not as urgent as ensuring airway patency. Administering antibiotics and initiating droplet precautions (Choice C) are important but not the immediate priority in this scenario. Therefore, Choice D is the correct first action to ensure the child's safety and optimal care.