Expiratory grunting is a sign of:

Correct Answer: B

Rationale: In pediatric nursing, understanding respiratory distress signs is crucial for accurate assessment and intervention. Expiratory grunting is a protective mechanism seen in infants with pneumonia. This sound is produced when a child attempts to keep small airways open during exhalation to prevent alveolar collapse. Pneumonia is characterized by inflammation and consolidation of lung tissue, leading to impaired gas exchange and respiratory distress. Option A, asthma exacerbation, typically presents with wheezing rather than grunting. Asthma involves bronchoconstriction and airway inflammation, leading to wheezing on expiration. Pleural effusion (Option C) manifests as decreased breath sounds and dullness to percussion, not expiratory grunting. Croup (Option D) is marked by a barking cough and stridor, not expiratory grunting. Educationally, this question highlights the importance of recognizing specific respiratory distress cues in pediatric patients. Understanding these nuances aids in prompt identification of underlying conditions and appropriate management. By grasping these distinctions, nurses can deliver timely and targeted care, thereby optimizing outcomes for children with respiratory issues.

Correct Answer: C

Rationale: Atelectasis due to foreign body inhalation is a common pediatric emergency. The correct answer, C) Percussion note is usually normal, is the exception because in atelectasis, there is a lack of air in the affected lung leading to dullness on percussion due to consolidation. Option A) Mediastinum is pulled towards the affected side is correct because when atelectasis occurs, the mediastinum shifts towards the affected side due to the loss of lung volume. Option B) Intercostal spaces on the affected side may be narrowed is also correct because the affected lung collapses, leading to a decrease in the intercostal space width. Option D) Breath sounds are reduced is correct as well since atelectasis causes decreased or absent breath sounds over the affected area. In an educational context, understanding the clinical manifestations of atelectasis due to foreign body inhalation is crucial for pediatric nurses to provide prompt and effective care. Recognizing these signs and symptoms can aid in early detection and intervention, preventing potential complications such as respiratory distress. Nurses must be vigilant in assessing pediatric patients for respiratory issues to ensure timely and appropriate management.

Correct Answer: B

Rationale: The correct answer is B) Renal tubular acidosis. Normal anion gap metabolic acidosis occurs when there is an excess of non-volatile acid in the body or a loss of bicarbonate. Renal tubular acidosis is a condition where the kidneys are unable to effectively acidify urine, leading to the retention of acid in the body and subsequent metabolic acidosis. A) Diabetic ketoacidosis causes high anion gap metabolic acidosis due to the accumulation of ketones. C) Lactic acidosis results from the accumulation of lactic acid and causes high anion gap metabolic acidosis. D) Salicylate poisoning leads to high anion gap metabolic acidosis due to the presence of salicylic acid. Understanding the causes of normal anion gap metabolic acidosis is crucial for nurses caring for pediatric patients. By knowing the specific etiologies, nurses can provide appropriate interventions and monitor these patients effectively. Renal tubular acidosis, in particular, requires close monitoring of electrolyte levels and acid-base balance to prevent complications. Nurses play a critical role in the assessment and management of pediatric patients with metabolic disorders like renal tubular acidosis.

Correct Answer: C

Rationale: In pediatric nursing, understanding the causes of hyperkalemia is crucial for providing safe and effective care to children. In this scenario, the correct answer is C) Major trauma. Hyperkalemia with a normal total body potassium can occur in major trauma due to the redistribution of potassium from the intracellular space to the extracellular space. This shift leads to an elevated serum potassium level without an actual increase in total body potassium. Option A) Hyperaldosteronism is incorrect because this condition usually leads to hypokalemia, not hyperkalemia. Option B) Large amounts of potassium in IV fluids could cause hyperkalemia, but it would result in an elevated total body potassium level as well. Option D) Metabolic alkalosis typically does not directly cause hyperkalemia. Educationally, this question highlights the importance of recognizing different etiologies of hyperkalemia in pediatric patients. Understanding the pathophysiology behind each cause is essential for accurate assessment and intervention in clinical practice. By grasping these concepts, nurses can provide timely and appropriate care to children experiencing hyperkalemia in various clinical settings.

Correct Answer: C

Rationale: The Look-Listen-Feel procedure is a fundamental aspect of pediatric nursing assessment and is used to assess for breathing in a patient, particularly in emergency situations such as assessing a child's respiratory status. A) Option A is incorrect because assessing for responsiveness involves other methods, such as tapping the child's shoulder or calling their name, to check for their level of consciousness. B) Option B is incorrect because assessing for airway patency involves different maneuvers like the head-tilt/chin-lift or jaw-thrust maneuver to ensure a clear airway for breathing. C) The correct answer, C, is to assess for breathing. During the Look-Listen-Feel procedure, the nurse visually inspects the rise and fall of the child's chest, listens for breath sounds, and feels for air movement on their cheek to determine if the child is breathing adequately. D) Option D is incorrect because assessing for circulation involves checking for a pulse and assessing skin color, temperature, and capillary refill time to evaluate the child's circulatory status, which is a separate aspect of the pediatric assessment. In pediatric nursing, knowing how to perform a systematic assessment, such as the Look-Listen-Feel procedure, is crucial for identifying and managing potential respiratory issues promptly. Understanding the rationale behind each step of the assessment helps nurses provide timely and appropriate interventions to ensure the well-being of pediatric patients.