a 14 month old child is admitted to the hospital with laryngotracheobronchitis ltb which assessment findings should the nurse expect
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Nursing Elites

ATI RN

RN Nursing Care of Children 2019 With NGN

1. A 14-month-old child is admitted to the hospital with laryngotracheobronchitis (LTB). Which assessment findings should the nurse expect?

Correct answer: C

Rationale: The correct answer is C: 'Barking cough and inspiratory stridor.' Classic signs of laryngotracheobronchitis (LTB) include a barking cough, often described as a seal-like cough, and inspiratory stridor, which is a high-pitched sound heard during inspiration. These symptoms occur due to inflammation and narrowing of the upper airway. Choices A, B, and D are incorrect as they do not align with the typical assessment findings of LTB. Cyanosis and dyspnea (Choice A) may occur in severe cases but are not specific to LTB. Productive cough and high fever (Choice B) are more indicative of lower respiratory tract infections. Pale laryngeal and dyspnea (Choice D) are not characteristic findings of LTB.

2. A 12-year-old child is injured in a bicycle accident. When considering the possibility of renal trauma, the nurse should consider what factor?

Correct answer: D

Rationale: The amount of hematuria is not a reliable indicator of the severity of renal trauma, as even minor injuries can cause significant bleeding, while severe injuries may result in little or no visible blood. Renal trauma should be evaluated through imaging and clinical assessment.

3. In the newborn, into what muscle is intramuscular vitamin K administered?

Correct answer: D

Rationale: In newborns, intramuscular vitamin K is traditionally administered into the vastus lateralis muscle. This site is preferred due to its large muscle mass and accessibility. The dorsogluteal site is not recommended for newborns due to the risk of injury to the sciatic nerve. The deltoid site is also not recommended for newborns. The rectus femoris muscle is not commonly used for intramuscular injections in newborns.

4. A girl, age 5 1/2 years, has been sent to the school nurse for urinary incontinence three times in the past 2 days. The nurse should recommend to her parent that the first action is to have the child evaluated for what condition?

Correct answer: C

Rationale: Urinary tract infections are a common cause of sudden onset urinary incontinence in children. While school phobia and ADHD can cause behavioral changes, a medical condition like a UTI should be ruled out first.

5. The nurse needs to take the blood pressure of a small child. Of the cuffs available, one is too large and one is too small. The best nursing action is which?

Correct answer: D

Rationale: It is essential to use the correct cuff size for accurate blood pressure readings; if the proper size is not available, it's best to wait until it can be obtained.

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