A nurse is caring for a 6-week-old infant.
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.
The Correct Answer is []
Correct Answers:
Condition Most Likely Experiencing: C
Actions to Take: A, B
Parameters to Monitor: B, C
Rationale:
Condition Most Likely Experiencing
A. Pyloric stenosis causes projectile vomiting, dehydration, and hunger.
B. Cystic fibrosis causes chronic respiratory infections, steatorrhea, and failure to thrive.
C. 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.
D. Respiratory syncytial virus bronchiolitis causes wheezing, coughing, and respiratory distress.
Actions to Take
A. Elevating the head of the bed can help reduce the workload of the heart and improve breathing.
B. Digoxin can increase the contractility of the heart and decrease the heart rate.
C. Contact precautions are not indicated for congestive heart failure, but for infections that are transmitted by direct or indirect contact.
D. 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
A. Number of steatorrhea stools is not relevant for congestive heart failure, but for cystic fibrosis or other malabsorption disorders.
B. Intake and output can indicate fluid balance and renal function.
C. Respiratory status can reflect cardiac function and oxygenation.
D. Presence of periorbital edema is not a parameter to monitor, but a sign of fluid overload.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Lavender oil is commonly used for relaxation and calming effects.
B. Eucalyptus oil is more commonly used for respiratory issues and may not be as suitable for relaxation.
C. Jasmine oil is often used for its pleasant scent but may not have the same relaxation properties as lavender.
D. Tea tree oil is typically used for its antimicrobial properties and may not be as effective for relaxation purposes as lavender.
Correct Answer is D
Explanation
Rationale:
A. While informing the client to contact the pharmacy is appropriate, it does not address the immediate need for understanding the medication.
B. Providing instructions to the client's parent may not respect the adolescent's autonomy and privacy regarding their healthcare.
C. Instructing the client's parents to write down the information may not involve the adolescent in the learning process or address their individual needs.
D. Asking how the client prefers to learn new information demonstrates respect for the adolescent's autonomy and preferences, facilitating effective communication and understanding.
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