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1. Question1 point(s)
Category: Physiological Integrity
A client with bacterial pneumonia is admitted to the pediatric unit. What would
the nurse expect the admitting assessment to reveal?
A. High fever
Correct Answer
B. Nonproductive cough
Incorrect
C. Rhinitis
D. Vomiting and diarrhea
Incorrect
Correct Answer: A. High fever
,If the child has bacterial pneumonia, a high fever is usually present. Increased
temperature (usually more than 38 C or 100.4 F) or fever with tachycardia and/or
chills and sweats is a major clinical finding. Physical findings also vary from patient
to patient and mainly depend on the severity of lung consolidation, the type of
organism, the extent of the infection, host factors, and existence or nonexistence
of pleural effusion.
Option B: Bacterial pneumonia usually presents with a productive cough, not a
nonproductive cough. The presence of a productive cough is the most common
and significant presenting symptom. The lower respiratory tract is not sterile, and
it always is exposed to environmental pathogens. Invasion and propagation of the
above-mentioned bacteria into lung parenchyma at alveolar level causes bacterial
pneumonia, and the body’s inflammatory response against it causes the clinical
syndrome of pneumonia.
Option C: Rhinitis is often seen with viral pneumonia. Features in the history of
bacterial pneumonia may vary from indolent to fulminant. Clinical manifestation
includes both constitutional findings and findings due to damage to the lung and
related tissue.
Option D: Vomiting and diarrhea are usually not seen with pneumonia. Atypical
pneumonia presents with pulmonary and extrapulmonary manifestations, such as
Legionella pneumonia, often presents with altered mentation and gastrointestinal
symptoms.
2. Question1 point(s)
,Category: Safe and Effective Care Environment
The nurse is caring for a client admitted with epiglottitis. Because of the
possibility of complete obstruction of the airway, which of the following should
the nurse have available?
A. Intravenous access supplies
B. A tracheostomy set
Correct
C. Intravenous fluid administration pump
D. Supplemental oxygen
Correct
Correct Answer: B. A tracheostomy set
For a child with epiglottitis and the possibility of complete obstruction of the
airway, emergency tracheostomy equipment should always be kept at the
bedside. Prepare for intubation or tracheostomy; Anticipate the need of an
artificial airway. An artificial airway is required to promote oxygenation and
ventilation and prevent aspiration.
, Option A: Administer IV antibiotics as ordered. After obtaining blood and
epiglottic cultures, second-or-third generation cephalosporins and beta-
lactamase-resistant antibiotics should be started as soon as possible.
Option C: Discourage examining throat with a tongue blade or taking throat
culture unless immediate emergency equipment and personnel at hand. Position
the child in a sitting up and leaning forward position with mouth open and tongue
out (“tripod” position). Allows maximum entry of air into the lungs for improved
oxygenation.
Option D: Oxygen will not treat an obstruction. Endotracheal intubation must be
readily available; assist with tracheostomy if needed or prepare for the procedure
in surgery. Establishes airway if obstruction present and respiratory failure and
asphyxia are imminent.
3. Question1 point(s)
Category: Physiological Integrity
A 25-year-old client with Grave’s disease is admitted to the unit. What would the
nurse expect the admitting assessment to reveal?
A. Bradycardia
B. Decreased appetite
C. Exophthalmos
Correct Answer