A five-year-old child with HIV presents with dry cough, shortness of breath, and no weight gain for the past year and is diagnosed with lymphoid interstitial pneumonitis (LIP). The nurse develops the care plan based on the knowledge that:
The child should be put on Airborne Precautions.
Lymphoid interstitial pneumonitis (LIP) is rarely seen in children with AIDS.
Lymphoid interstitial pneumonitis (LIP) is a common AIDS-defining condition in children with HIV.
These symptoms need to be treated immediately with antibiotics.
The Correct Answer is C
Choice A reason: This statement is incorrect, as Airborne Precautions are not indicated for patients with LIP, unless they have other infections that are transmitted by airborne particles, such as tuberculosis, measles, or chickenpox. Airborne Precautions include wearing a respirator or N95 mask when entering the patient's room, placing the patient in a negative-pressure isolation room with the door closed, and limiting the movement of the patient outside the room.
Choice B reason: This statement is incorrect, as LIP is not rarely seen in children with AIDS, but rather one of the most common pulmonary complications of HIV infection in children. LIP affects about 30% to 40% of children with HIV, and is more prevalent in younger children than older children or adults.
Choice C reason: This statement is correct, as LIP is a common AIDS-defining condition in children with HIV. AIDS-defining conditions are illnesses that occur in people with advanced HIV infection and indicate a severe immunosuppression. LIP is a chronic inflammatory disorder of the lungs that causes lymphocytic infiltration of the interstitium and alveoli, leading to respiratory symptoms and impaired gas exchange.
Choice D reason: This statement is incorrect, as antibiotics are not the first-line treatment for LIP, unless there is a bacterial superinfection. Antibiotics do not target the underlying cause of LIP, which is the HIV infection and the associated immune dysfunction. The main treatment for LIP is antiretroviral therapy (ART), which suppresses the viral replication and improves the immune status of the patient. Corticosteroids may also be used to reduce the inflammation and improve the lung function.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D"]
Explanation
Choice A reason: Starting bolus feedings to stretch the stomach is not recommended for a child with Nissen fundoplication as it can cause increased pressure on the surgical site and lead to complications such as bleeding, perforation, or slippage of the wrap.
Choice B reason: Venting gastrostomy tube is a correct answer as it allows for the release of gas and fluids from the stomach and prevents gastric distension and discomfort. A gastrostomy tube is often placed during Nissen fundoplication to facilitate feeding and venting.
Choice C reason: Keeping child flat in bed to increase absorption of food is not advised for a child with Nissen fundoplication as it can increase the risk of aspiration and pneumonia. The child should be positioned at a 30-degree angle or higher after feeding to prevent reflux.
Choice D reason: Observing for abdominal distension, flushing and hypotension which may indicate dumping syndrome is a correct answer as it is a potential complication of Nissen fundoplication. Dumping syndrome occurs when food moves too quickly from the stomach to the small intestine, causing symptoms such as abdominal cramps, nausea, diarrhea, sweating, and dizziness.
Correct Answer is C
Explanation
Choice A reason: This statement is incorrect, as sodium excess is not likely to cause the symptoms of poor skin turgor, weight loss, irritability, and tachycardia in an infant. Sodium excess, or hypernatremia, is a condition where the blood sodium level is too high, which can result from excessive intake or loss of water. The symptoms of sodium excess may include thirst, dry mouth, confusion, seizures, or coma.
Choice B reason: This statement is incorrect, as overhydration is not likely to cause the symptoms of poor skin turgor, weight loss, irritability, and tachycardia in an infant. Overhydration, or hypervolemia, is a condition where the body has too much fluid, which can result from excessive intake or retention of water. The symptoms of overhydration may include edema, weight gain, shortness of breath, or crackles in the lungs.
Choice C reason: This statement is correct, as dehydration is the most likely cause of the symptoms of poor skin turgor, weight loss, irritability, and tachycardia in an infant. Dehydration is a condition where the body loses more fluid than it takes in, which can result from vomiting, diarrhea, fever, or inadequate intake of water. The symptoms of dehydration may include dry skin, sunken eyes, decreased urine output, or lethargy.
Choice D reason: This statement is incorrect, as calcium excess is not likely to cause the symptoms of poor skin turgor, weight loss, irritability, and tachycardia in an infant. Calcium excess, or hypercalcemia, is a condition where the blood calcium level is too high, which can result from hyperparathyroidism, malignancy, or excessive intake of vitamin D or calcium. The symptoms of calcium excess may include nausea, constipation, muscle weakness, or kidney stones.
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