A nurse is monitoring an infant who is 6 months old and has sneezing, coughing, nasal congestion, intermittent fever, and apneic spells. The nurse should recognize these findings are consistent with which of the following diagnoses?
Epiglottitis
Bronchiolitis
Influenza
Croup
The Correct Answer is B
Choice A reason: Epiglottitis is a life-threatening condition that causes inflammation and swelling of the epiglottis, the flap of tissue that covers the entrance to the trachea. It can block the airway and cause respiratory distress. The signs and symptoms of epiglottitis include drooling, dysphagia, dysphonia, high fever, and tripod position. Epiglottitis is rare in infants and more common in children aged 2-6 years.
Choice B reason: Bronchiolitis is a viral infection that causes inflammation and mucus production in the bronchioles, the smallest airways in the lungs. It can impair gas exchange and cause respiratory distress. The signs and symptoms of bronchiolitis include sneezing, coughing, nasal congestion, wheezing, tachypnea, retractions, and apneic spells. Bronchiolitis is common in infants and children under 2 years of age, especially during the winter months.
Choice C reason: Influenza is a viral infection that affects the respiratory system. It can cause fever, chills, headache, muscle aches, fatigue, sore throat, cough, and nasal congestion. Influenza can also lead to complications such as pneumonia, otitis media, and sinusitis. Influenza is common in children and adults of all ages, especially during the flu season.
Choice D reason: Croup is a viral infection that causes inflammation and narrowing of the larynx and trachea. It can cause a characteristic barking cough, hoarseness, stridor, and respiratory distress. Croup is common in children aged 6 months to 3 years, especially during the fall and winter months.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Red currant jelly stools are typically associated with intussusception, not pyloric stenosis. In pyloric stenosis, the stool would not have this appearance.
Choice B reason: Distended neck veins are not a clinical manifestation of pyloric stenosis. They are more commonly associated with cardiac or respiratory issues.
Choice C reason: Projectile vomiting is a classic symptom of pyloric stenosis. It occurs due to the obstruction at the pylorus, which prevents stomach contents from passing into the small intestine.
Choice D reason: A bulged abdomen is not specific to pyloric stenosis. While the abdomen may appear full, 'bulged' is not the precise term used to describe the manifestation in pyloric stenosis.
Correct Answer is D
Explanation
Choice A reason: This statement is normal, as an infant who is 2 months old should have an axillary temperature between 36.5°C and 37.5°C (97.7°F and 99.5°F). The nurse should assess the infant's temperature using an axillary or tympanic method, as oral and rectal methods are not recommended for infants.
Choice B reason: This statement is normal, as an infant who is 2 months old should have a heart rate between 100 and 160 beats per minute. The nurse should assess the infant's heart rate by auscultating the apical pulse for a full minute.
Choice C reason: This statement is normal, as an infant who is 2 months old should have a respiratory rate between 25 and 40 breaths per minute. The nurse should assess the infant's respiratory rate by observing the chest movements for a full minute.
Choice D reason: This statement is abnormal, as an infant who is 2 months old should have a weight gain of about 150 to 200 grams (5 to 7 ounces) per week. The current weight of the infant indicates a failure to thrive, as it is below the 5th percentile for the age and gender. The nurse should report this finding to the provider and assess the infant's feeding habits, growth chart, and developmental milestones.
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