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.
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Related Questions
Correct Answer is D
Explanation
Rationale:
A. Chlorothiazide is a diuretic and is not indicated during a seizure.
B. Holding the child down during a seizure can lead to injury and is not recommended. It's essential to ensure the child's safety by protecting the head from injury and removing any objects that could cause harm.
C. Placing the child in a prone position during a seizure can compromise their ability to breathe and is not recommended. Instead, the child should be placed in a safe position on their side to prevent aspiration.
D. Timing the duration of the seizure is crucial for medical management and documentation purposes. This action allows healthcare providers to assess the
severity of the seizure and determine the need for intervention or medication administration.
Correct Answer is B
Explanation
Rationale:
A. Retesting in a week may be necessary, but notifying the public health department is a more immediate concern.
B. Notifying the public health department is essential for contact tracing and preventing the spread of syphilis.
C. Involving the patient's parents may not be appropriate for a 20-year-old patient.
D. Metronidazole is not typically used to treat syphilis; penicillin or other antibiotics are the standard treatment.
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