Page 1053 - Saunders Comprehensive Review For NCLEX-RN

355. Answer: 4

Rationale: Cystic fibrosis is a chronic multisystem disorder (autosomal recessive
trait disorder) characterized by exocrine gland dysfunction. The mucus produced by
the exocrine glands is abnormally thick, tenacious, and copious, causing obstruction
of the small passageways of the affected organs, particularly in the respiratory,
gastrointestinal, and reproductive systems. Adequately protecting children with
cystic fibrosis from communicable diseases by immunization is essential. In addition
to the basic series of immunizations, a yearly influenza immunization is
recommended for children with cystic fibrosis. Options 1, 2, and 3 are incorrect.
Test-Taking Strategy: Eliminate options 1, 2, and 3 because they are comparable
or alike, indicating that the immunization schedule will be adjusted in some way.
Recalling the importance of protection from communicable diseases, particularly in
children with a disorder such as cystic fibrosis, will assist in directing you to the
correct option.
Level of Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Teaching and Learning
Content Area: Pediatrics: Throat/Respiratory
Health Problem: Pediatric-Specific: Cystic fibrosis
Priority Concepts: Client Education; Health Promotion
Reference: McKinney et al. (2018), p. 1071.
https://www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html

356. Answer: 2

Rationale: Epiglottitis is a bacterial form of croup. A primary concern is that it can
progress to acute respiratory distress. Clinical manifestations suggestive of airway
obstruction include tripod positioning (leaning forward while supported by arms,
chin thrust out, mouth open), nasal flaring, the use of accessory muscles for
breathing, and the presence of stridor. Option 4 is an incorrect position. Options 1
and 3 are incorrect because epiglottitis causes tachycardia and a high fever.
Test-Taking Strategy: Focus on the subject, manifestations of airway obstruction
in a child with epiglottitis. Eliminate option 1 first, because tachycardia rather than
bradycardia would occur in a child experiencing respiratory distress. Eliminate
option 3 next, knowing that a high fever occurs with epiglottitis. From the remaining
options, visualize the descriptions in each and determine which position would best
assist a child experiencing respiratory distress.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Pediatrics: Throat/Respiratory
Health Problem: Pediatric-Specific: Croup
Priority Concepts: Clinical Judgment; Gas Exchange
Reference: McKinney et al. (2018), pp. 1046-1047.

357. Answer: 4

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