ATLS 10TH EDITION TRIAGE PATIENT
SCENARIOS QUESTIONS AND ANSWERS
STUDY GUIDE
◉ ANS: A
Dyspnea is labored breathing. Tachypnea is rapid breathing.
Hypopnea is breathing that is too shallow.
Orthopnea is difficulty breathing except in an upright position.
DIF: Cognitive Level: Remember REF: p. 639
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic
Adaptation.
Answer: A nurse is charting that a hospitalized child has labored
breathing. Which describes labored breathing?
a. Dyspnea
b. Tachypnea
c. Hypopnea
d. Orthopnea
◉ ANS: A
,Cool-mist vaporizers are safer than steam vaporizers, and little
evidence exists to show any advantages to
steam. The cost of cool-mist and steam vaporizers is comparable.
Steam loosens secretions, not dries
them. Both may promote a more comfortable environment, but cool-
mist vaporizers present decreased
risk for burns and growth of organisms.
DIF: Cognitive Level: Understand REF: p. 639
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk
Potential.
Answer: Which explains why cool-mist vaporizers rather than steam
vaporizers are recommended in home treatment of childhood
respiratory tract infections?
a. They are safer.
b. They are less expensive.
c. Respiratory secretions are dried.
d. A more comfortable environment is produced.
◉ ANS: A
Vasoconstrictive nose drops such as phenylephrine (Neo-
Synephrine) should not be used for more than 3
,days to avoid rebound congestion. Drops should be discarded after
one illness because they may become
contaminated with bacteria. Vasoconstrictive nose drops can have a
rebound effect after 3 days of use.
Drops administered before feedings are more helpful.
DIF: Cognitive Level: Apply REF: p. 639
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and
Parenteral Therapies.
Answer: Decongestant nose drops are recommended for a 10-
month-old infant with an upper respiratory tract infection.
Instructions for nose drops should include which action?
a. Avoid using for more than 3 days.
b. Keep drops to use again for nasal congestion.
c. Administer drops until nasal congestion subsides.
d. Administer drops after feedings and at bedtime.
◉ ANS: D
Preventing dehydration by small frequent feedings is an important
intervention in the febrile child. Tepid
water baths may induce shivering, which raises temperature. Food
should not be forced; it may result in
, the child vomiting. The febrile child should be dressed in light, loose
clothing.
DIF: Cognitive Level: Apply REF: p. 640
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic
Adaptation.
Answer: Which is an appropriate nursing intervention when caring
for an infant with an upper respiratory tract infection and elevated
temperature?
a. Give tepid water baths to reduce fever.
b. Encourage food intake to maintain caloric needs.
c. Have child wear heavy clothing to prevent chilling.
d. Give small amounts of favorite fluids frequently to prevent
dehydration.
◉ ANS: D
If an infant with nasopharyngitis shows signs of an earache, it may
mean a secondary bacterial infection is
present and the infant should be referred to a practitioner for
evaluation. Irritability is common in an
infant with a viral illness. Cough can be a sign of nasopharyngitis.
Fever is common in viral illnesses.
DIF: Cognitive Level: Apply REF: p. 640
SCENARIOS QUESTIONS AND ANSWERS
STUDY GUIDE
◉ ANS: A
Dyspnea is labored breathing. Tachypnea is rapid breathing.
Hypopnea is breathing that is too shallow.
Orthopnea is difficulty breathing except in an upright position.
DIF: Cognitive Level: Remember REF: p. 639
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Physiologic
Adaptation.
Answer: A nurse is charting that a hospitalized child has labored
breathing. Which describes labored breathing?
a. Dyspnea
b. Tachypnea
c. Hypopnea
d. Orthopnea
◉ ANS: A
,Cool-mist vaporizers are safer than steam vaporizers, and little
evidence exists to show any advantages to
steam. The cost of cool-mist and steam vaporizers is comparable.
Steam loosens secretions, not dries
them. Both may promote a more comfortable environment, but cool-
mist vaporizers present decreased
risk for burns and growth of organisms.
DIF: Cognitive Level: Understand REF: p. 639
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk
Potential.
Answer: Which explains why cool-mist vaporizers rather than steam
vaporizers are recommended in home treatment of childhood
respiratory tract infections?
a. They are safer.
b. They are less expensive.
c. Respiratory secretions are dried.
d. A more comfortable environment is produced.
◉ ANS: A
Vasoconstrictive nose drops such as phenylephrine (Neo-
Synephrine) should not be used for more than 3
,days to avoid rebound congestion. Drops should be discarded after
one illness because they may become
contaminated with bacteria. Vasoconstrictive nose drops can have a
rebound effect after 3 days of use.
Drops administered before feedings are more helpful.
DIF: Cognitive Level: Apply REF: p. 639
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and
Parenteral Therapies.
Answer: Decongestant nose drops are recommended for a 10-
month-old infant with an upper respiratory tract infection.
Instructions for nose drops should include which action?
a. Avoid using for more than 3 days.
b. Keep drops to use again for nasal congestion.
c. Administer drops until nasal congestion subsides.
d. Administer drops after feedings and at bedtime.
◉ ANS: D
Preventing dehydration by small frequent feedings is an important
intervention in the febrile child. Tepid
water baths may induce shivering, which raises temperature. Food
should not be forced; it may result in
, the child vomiting. The febrile child should be dressed in light, loose
clothing.
DIF: Cognitive Level: Apply REF: p. 640
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic
Adaptation.
Answer: Which is an appropriate nursing intervention when caring
for an infant with an upper respiratory tract infection and elevated
temperature?
a. Give tepid water baths to reduce fever.
b. Encourage food intake to maintain caloric needs.
c. Have child wear heavy clothing to prevent chilling.
d. Give small amounts of favorite fluids frequently to prevent
dehydration.
◉ ANS: D
If an infant with nasopharyngitis shows signs of an earache, it may
mean a secondary bacterial infection is
present and the infant should be referred to a practitioner for
evaluation. Irritability is common in an
infant with a viral illness. Cough can be a sign of nasopharyngitis.
Fever is common in viral illnesses.
DIF: Cognitive Level: Apply REF: p. 640
