Section: Questions Set E
Explanation:
(A, C, D) These answers are incorrect. (B) Normal fluid requirement for this pediatric client is based on the fact that 0-10 kg of weight equals 100 mL/kg per day. This infant weighs 15 pounds (6.8 kg). Thus, 100 mL X 6.8
680 mL/day.

Section: Questions Set E
Explanation:
(A) This response is nontherapeutic because it belittles the client's response and gives a meaningless rationalization. (B) This response acknowledges the client's feelings and demonstrates the therapeutic offering of self by the nurse. (C) This response is nontherapeutic because it does not focus on the client's feelings and offers false reassurance. (D) This response is nontherapeutic because it belittles the client's feelings and offers her advice.

Explanation
(A) A priority nursing goal is attending to the client's safety and well-being. Reorient frequently, remove dangerous objects, and maintain consistent environment. (B) Short, frequent visits are recommended to avoid overstimulation and fatigue. (C) Short, concise, simple explanations are easier to understand. (D) Mental capability and attention span deficits make learning difficult and frustrating.

Explanation
(A) Clinical manifestations of acute tracheitis include a 2-3 day history of URI, croupy cough, stridor, purulent secretions, high fever. (B) Clinical manifestations of spasmodic croup include a history of URI, croupy cough, stridor, dyspnea, low-grade fever, and a slow progression. The age group most affected is 3 months to 3 years. (C) Three clinical observations have been found to be predictive of epiglottitis: the presence of drooling, absence of spontaneous cough, and agitation.Epiglottitis has a rapid onset that is accompanied by high fever and dysphagia. (D) Clinical manifestations of acute laryngotracheobronchitis (LTB) include slow onset with a history of URI, low-grade fever, stridor, brassy cough, and irritability.

Section: Questions Set A
Explanation:
(A, B, D) These occur in both tension pneumothorax and open pneumothorax. (C) The tension pneumothorax acts like a one-way valve so that the pneumothorax increases with each breath. Eventually, it occupies enough space to shift mediastinal tissue toward the unaffected side away from the midline. Tracheal deviation, movement of point of maximum impulse, and decreased cardiac output will occur. The other three options will occur in both types of pneumothorax.