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A nurse is caring for a 6-week-old infant.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Condition Most Likely Experiencing

Pyloric stenosis causes projectile vomiting, dehydration, and hunger.
Cystic fibrosis causes chronic respiratory infections, steatorrhea, and failure to thrive.
The condition that the infant is most likely experiencing is congestive heart failure, which can cause poor weight gain, tachypnea, decreased appetite, and periorbital edema.
Respiratory syncytial virus bronchiolitis causes wheezing, coughing, and respiratory distress.

Actions to Take

Digoxin is a medication commonly prescribed to manage congestive heart failure in infants by improving cardiac contractility and reducing heart rate.
Elevating the head of the bed helps reduce venous return to the heart, thereby decreasing preload and relieving symptoms of congestion in congestive heart failure.
Contact precautions are not indicated for congestive heart failure, but for infections that are transmitted by direct or indirect contact.
Chest physiotherapy and postural drainage are not indicated for congestive heart failure, but for conditions that cause excessive mucus production and retention.

Parameters to Monitor

Number of steatorrhea stools is not relevant for congestive heart failure, but for cystic fibrosis or other malabsorption disorders.
Monitoring intake and output is crucial in assessing fluid balance, especially in congestive heart failure where fluid retention can lead to volume overload.
Monitoring respiratory status is essential in congestive heart failure to assess for signs of pulmonary congestion and respiratory distress, such as tachypnea, retractions, and crackles.
Presence of periorbital edema is not a parameter to monitor, but a sign of fluid overload.

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Correct Answer is B

Explanation

A. Toddlers thrive on routines and consistency, which provide them with security and predictability.
B. Toddlers are in a stage of development where they assert their independence and autonomy by saying "no" or "mine" to almost everything. This is a normal and healthy behavior that reflects their growing sense of self and identity. The nurse should explain to the guardian that this behavior is not meant to be defiant or disrespectful, but rather a way of exploring their environment and expressing their preferences.
C. Toddlers are typically emotionally labile, meaning they can experience rapid changes in mood and emotions.
D. Toddlers may display increased independence rather than increased dependency as they strive to assert their autonomy.

A. “Discontinue this medication if gastrointestinal upset occurs.” B. “Limit your child’s intake of potassium-rich foods.” C. “Expect that this medication will stimulate a growth spurt.” D. Monitor your child for indications of infection.”

Correct Answer is D

Explanation

A. Instructing the parent to discontinue prednisone if gastrointestinal upset occurs is not appropriate, as abrupt discontinuation of corticosteroids can lead to adrenal insufficiency. Monitoring for and managing gastrointestinal upset while continuing the medication as prescribed is more appropriate.
B. Limiting intake of potassium-rich foods is not specifically indicated with prednisone therapy. Prednisone may increase the risk of potassium loss, but dietary adjustments should be made under medical guidance.
C. Prednisone can affect growth in children, but it is more commonly associated with slowing growth rather than stimulating a growth spurt. This statement is misleading and not accurate.
D. Monitoring the child for indications of infection is crucial when taking prednisone, as corticosteroids can suppress the immune system and increase susceptibility to infections. This statement addresses an important aspect of medication safety and is the priority in discharge teaching.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to the guardian of a 2-year-old child about typical toddler behavior. Which of the following behaviors should the nurse include?

Correct Answer is B

Explanation

A nurse is providing discharge teaching to a parent of a child who has juvenile idiopathic arthritis and a new prescription for prednisone. Which of the following statements should the nurse include in the teaching?

Correct Answer is D

Explanation

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