A nurse is assisting in the care of an 8-month-old infant in the pediatric unit.
Complete the diagram by dragging from the choices below to specify what condition the infant is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the infant's progress.
The Correct Answer is []
Condition: Viral Upper Respiratory Infection (URI).
2 actions:
- Administer saline nasal drops,
- Encourage oral hydration.
2 parameters:
- Respiratory rate,
- Oxygen saturation.
Rationale for correct condition: A viral upper respiratory infection (URI) is indicated by the infant's symptoms of nasal congestion, cough, and mild intercostal retractions. The clear breath sounds suggest the absence of lower respiratory tract infection. The fever and irritability are consistent with a viral infection. The normal oxygen saturation level supports a less severe respiratory condition. The history of reduced feeding aligns with the discomfort caused by nasal congestion.
Rationale for actions: Administering saline nasal drops helps to relieve nasal congestion, improving the infant's breathing and comfort. Saline is safe and effective for clearing nasal passages in infants. Encouraging oral hydration ensures the infant remains well-hydrated, which is crucial for overall health and recovery. Adequate hydration helps thin mucus secretions, making it easier for the infant to breathe. Administering nebulized albuterol is more appropriate for bronchiolitis or asthma. Obtaining a chest X-ray is unnecessary without signs of pneumonia. Starting supplemental oxygen is not indicated with normal oxygen saturation.
Rationale for parameters: Monitoring respiratory rate helps assess the infant's breathing pattern and detect any signs of respiratory distress. Changes in respiratory rate can indicate worsening or improvement of the condition. Oxygen saturation monitoring ensures the infant maintains adequate oxygen levels, crucial for identifying any need for supplemental oxygen. Serum electrolyte levels are not directly related to a URI. Capillary refill time is important but not specific to respiratory conditions. Urine output monitors hydration but is less specific for respiratory assessment.
Rationale for incorrect conditions: Bronchiolitis presents with more severe respiratory distress and wheezing. Pneumonia would show abnormal lung sounds and possibly a higher fever. Foreign body aspiration would cause sudden onset of symptoms and possibly localized wheezing or stridor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Facial edema is not a typical manifestation of a urinary tract infection (UTI). UTIs primarily affect the urinary system, causing symptoms such as painful urination, increased frequency, and urgency. Facial edema is more commonly associated with kidney issues such as nephrotic syndrome or systemic conditions like heart failure. It is important to look for signs directly related to the urinary system when diagnosing a UTI.
Choice B rationale
Increased temperature, or fever, is a common manifestation of a urinary tract infection, especially in children. Fever occurs as the body's immune response to infection, attempting to fight off the bacteria causing the UTI. Monitoring the child's temperature and other symptoms is crucial in diagnosing and managing UTIs, ensuring appropriate treatment to prevent complications.
Choice C rationale
Muscle twitching is not typically associated with urinary tract infections. Muscle twitching can be caused by electrolyte imbalances, neurological issues, or muscle fatigue. UTIs usually present with symptoms related to the urinary system, such as dysuria, frequency, and abdominal pain. It is essential to focus on urinary symptoms when suspecting a UTI.
Choice D rationale
Moist mucus membranes do not indicate a urinary tract infection. This finding is more related to hydration status and general health. UTIs are characterized by urinary symptoms and systemic signs such as fever. Assessing for signs like dysuria, frequency, urgency, and abdominal discomfort is more relevant in diagnosing a UTI.
Correct Answer is {"A":{"answers":"A,B,C"},"B":{"answers":"A,B,C"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"C"}}
Explanation
- Jitteriness: Jitteriness can be seen in hypoglycemia (due to low blood sugar), neonatal sepsis (which causes systemic effects including jitteriness), and neonatal abstinence syndrome (due to withdrawal from maternal substances).
- Poor feeding: Poor feeding is consistent with hypoglycemia (due to low energy reserves), neonatal sepsis (due to general ill-health), and neonatal abstinence syndrome (as a withdrawal symptom).
- Petechiae on the chest: Petechiae is a sign of neonatal sepsis, which can result from bacterial infections or other causes affecting the clotting system. It is not typically seen in hypoglycemia, neonatal abstinence syndrome, or hyperbilirubinemia.
- Blood glucose 35 mg/dL: This is a hallmark sign of hypoglycemia, indicating a dangerously low level of glucose in the blood.
- High-pitched cry: A high-pitched cry is a classic symptom of neonatal abstinence syndrome, often seen in infants withdrawing from opioids or other substances. It is not a typical sign of hypoglycemia, neonatal sepsis, or hyperbilirubinemia.
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