Question 1

The nurse is assessing a 7-year-old boy with pharyngitis. The nurse would least likely expect to assess which of the following?

Accepted Answer

Difficulty breathing is not a common symptom of pharyngitis, whereas difficulty swallowing, rash, sore throat, and headache are more typical symptoms.

Question 2

The nurse hears wheezing when auscultating a 4-year-old. Which of the following conditions would the nurse most likely rule out based on the assessment findings?

Accepted Answer

Wheezing is a common symptom associated with conditions that cause obstruction or narrowing of the lower airways, such as bronchiolitis, asthma, and cystic fibrosis. Influenza primarily affects the upper respiratory tract and is less likely to cause wheezing compared to the other conditions listed.

Question 3

The nurse is examining an 8-year-old boy with tachycardia and tachypnea. The nurse anticipates which of the following as most helpful in determining the extent of the child's hypoxia?

Accepted Answer

Pulse oximetry is the most helpful tool in determining the extent of a child's hypoxia as it provides immediate, non-invasive measurement of oxygen saturation in the blood, which directly reflects the child's oxygenation status.

Question 4

A rapid strep test has confirmed that a 5-year-old girl has a group A Streptococcus infection. When teaching the parents about measures to implement, which of the following would be the least immediate concern?

Accepted Answer

Discarding the child's toothbrush is the least immediate concern compared to the other options. Immediate concerns include administering antibiotic therapy to treat the infection, using a cool mist humidifier to ease throat discomfort, and encouraging fluid intake to prevent dehydration. Changing the toothbrush can be delayed until the infectious period is over to prevent reinfection, but it is not as urgent as starting treatment and ensuring comfort and hydration.

Question 5

A nurse is administering 100% oxygen to a child with a pneumothorax based on the understanding that this treatment is used primarily for which reason?

Accepted Answer

Administering 100% oxygen to a patient with a pneumotharynx can hasten the reabsorption of air from the pleural space. This is because a high concentration of oxygen increases the gradient for nitrogen (the main component of air) to be absorbed from the pleural space into the bloodstream, thereby potentially speeding up the resolution of the pneumothorax.

Question 6

Bacterial pneumonia is suspected in a 4-year-old boy with fever, headache, and chest pain. Which assessment finding would most likely indicate the need for this child to be hospitalized?

Accepted Answer

Tachypnea with retractions indicates significant respiratory distress, which is a common reason for hospitalization in children with pneumonia to ensure they receive appropriate respiratory support and monitoring.

Question 7

The nurse is assessing a 5-year-old girl who is anxious, has a high fever, speaks in a whisper, and sits up with her neck thrust forward. Based on these findings, which of the following would be least appropriate for the nurse to perform?

Accepted Answer

Visualizing the throat in a child with symptoms suggestive of epiglottitis (anxious appearance, high fever, whispering voice, sitting up with neck thrust forward) can provoke airway obstruction and is therefore the least appropriate action for the nurse to perform without proper preparation and support, such as having a skilled airway management team ready.

Question 8

The nurse is educating the parents of a 7-year-old boy with asthma about the medications that have been prescribed. Which of the following drugs would the nurse identify as an adjunct to a b₂-adrenergic agonist for treatment of bronchospasm?

Accepted Answer

Ipratropium is an anticholinergic medication that serves as an adjunct to beta-adrenergic agonists in the treatment of bronchospasm, particularly in conditions like asthma. It works by inhibiting the muscarinic cholinergic receptors and reducing intrinsic vagal tone of the airway, leading to bronchodilation.

Question 9

The nurse is caring for a 3-year-old girl with a respiratory disorder. The nurse anticipates the need for providing supplemental oxygen to the child when performing which of the following?

Accepted Answer

Suctioning a tracheostomy tube can lead to a decrease in oxygen levels, so supplemental oxygen is often provided to maintain adequate oxygenation during the procedure.

Question 10

The nurse is examining a 5-year-old boy. Which of the following signs or symptoms is a reliable first indication of respiratory illness in children?

Accepted Answer

Rapid, shallow breathing is a common and early sign of respiratory distress in children, indicating that they are working harder to breathe. This can be a reliable first indication of respiratory illness.

Question 11

A child requires supplemental oxygen therapy at 8 liters per minute. Which delivery device would the nurse most likely expect to be used?

Accepted Answer

A simple mask is typically used for delivering oxygen therapy at higher flow rates, such as 8 liters per minute, as it can provide a higher concentration of oxygen compared to a nasal cannula, which is usually used for lower flow rates.

Question 12

A group of nursing students are reviewing information about the variations in respiratory anatomy and physiology in children in comparison to adults. The students demonstrate understanding of the information when they identify which of the following?

Accepted Answer

Children have a higher metabolic rate and oxygen consumption per body weight compared to adults, which means they have less reserve and can develop hypoxemia more rapidly when there is a disruption in oxygen supply.

Question 13

The nurse is providing care to several children who have been brought to the clinic by the parents for complaints of cold-like symptoms. The nurse would most likely suspect sinusitis in which child?

Accepted Answer

Sinusitis is often suspected in the presence of symptoms such as thick, yellow nasal discharge and halitosis (bad breath), which are indicative of a bacterial infection, rather than just a common cold. This makes option D the most likely suspect for sinusitis.

Question 14

A parent asks the nurse about immunizing her 7-month-old daughter against the flu. Which response by the nurse would be most appropriate?

Accepted Answer

Children older than 6 months should receive the flu vaccine every year to protect against the influenza virus, as recommended by health authorities.

Question 15

A nurse is preparing a teaching program for a parenting group about preventing foreign body aspiration. Which of the following would the nurse include?

Accepted Answer

The answer of A nurse is preparing a teaching program...

Question 16

A child with a pneumothorax has a chest tube attached to a water seal system. When assessing the child, the nurse notices that the chest tube has become disconnected from the drainage system. Which of the following would the nurse do first?

Accepted Answer

Clamping the chest tube is the immediate action to prevent air from entering the pleural space, which could worsen the pneumothorax.

Question 17

A nurse is preparing a teaching plan for the family of a child with allergic rhinitis. When describing the immune reaction that occurs, the nurse would identify the role of which immunoglobulin?

Accepted Answer

IgE is the immunoglobulin primarily involved in allergic reactions, including allergic rhinitis. It binds to allergens and triggers the release of histamine and other chemicals from mast cells, leading to the symptoms of an allergic reaction.

Question 18

A group of nursing students are reviewing the medications used to treat asthma. The students demonstrate understanding of the information when they identify which agent as appropriate for an acute episode of bronchospasm?

Accepted Answer

Albuterol is a short-acting beta-agonist (SABA) that is commonly used for the quick relief of asthma symptoms such as an acute episode of bronchospasm. It works by relaxing the muscles in the airways and increasing airflow to the lungs.

Question 19

A nursing instructor is preparing a class on chronic lung disease. Which of the following would the instructor include when describing this disorder?

Accepted Answer

Chronic lung disease, also known as bronchopulmonary dysplasia, is most commonly seen in premature infants who have received oxygen therapy or mechanical ventilation.

Question 20

A nurse is teaching the parents of a child diagnosed with cystic fibrosis about medication therapy. Which of the following would the nurse instruct the parents to administer orally?

Accepted Answer

Pancreatic enzymes are administered orally to patients with cystic fibrosis to aid in the digestion of food, as the disease affects the pancreas' ability to produce natural enzymes.

Quiz 40: Nursing Care of the Child With an Alteration in Gas Exchange/Respiratory Disorder