A nurse is planning care for an adolescent who was admitted from the emergency department.

Exhibits

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

Answer and Explanation

The Correct Answer is []

Potential Condition: Viral Pneumonia

High fever (39.88°C/103.8°F), severe fatigue, chills, productive cough, and dyspnea suggest a respiratory infection. Bilateral lung consolidation on x-ray is consistent with viral pneumonia. Negative bacterial culture supports a viral rather than bacterial etiology. Elevated WBC count (12,300/mm³) is slightly above normal, which can occur with viral infections. Crackles in upper lobes, diminished breath sounds in lower lobes are common findings in pneumonia.

Actions to Take (Correct Choices)

Cluster client care to allow for rest: Viral pneumonia leads to fatigue and respiratory distress. Minimizing exertion conserves energy and improves recovery.

Administer prescribed antipyretic: Reduces fever, improves comfort, and helps decrease metabolic demand on the body.

Incorrect Actions and Rationale:

Replace pancreatic enzymes – This is necessary for cystic fibrosis, not viral pneumonia.

Maintain airborne precautions – Airborne precautions are required for tuberculosis (TB), not viral pneumonia. Pneumonia typically requires droplet precautions only if caused by a pathogen like influenza.

Obtain a peak respiratory flow rate – More relevant for asthma, not pneumonia.

Parameters to Monitor (Correct Choices)

Level of fatigue: Fatigue indicates worsening illness or improvement. Increasing exhaustion may suggest hypoxia or worsening pneumonia.

Oxygen saturation levels: 92% on room air is borderline low, requiring monitoring for worsening hypoxemia. Oxygen therapy may be needed if saturation drops further.

Incorrect Parameters:

Allergen triggers – Relevant for asthma, not viral pneumonia.

Diet high in protein and calcium – Important for cystic fibrosis, but not a primary concern for pneumonia management.

Blood glucose levels – More relevant for diabetes or steroid therapy, not viral pneumonia.

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Correct Answer is B

Explanation

A. Place the patch on the right eye for several hours daily would not be effective for treating amblyopia. The goal of patching is to encourage the use of the weaker (lazy) eye, so the good eye (left) must be patched.

B. Place the patch on the left eye for several hours daily is the correct approach to treat amblyopia, as it forces the right (weaker) eye to work and improve visual acuity.

C. Place the patch on the right eye for one hour daily would not effectively treat the amblyopia in the left eye, as it focuses on the wrong eye.

D. Alternate the patch from the right to the left eye hourly is not typically done. Consistent patching of the stronger (left) eye is recommended.

A. Itching and tenderness when manipulating the affected ear lobe B. Fullness in the ear and a clogged sensation without other systemic findings C. Edema and erythema of the external canal only D. Pulling on the affected ear, acute onset of fever and otalgia

Correct Answer is D

Explanation

A. Itching and tenderness when manipulating the affected ear lobe is more characteristic of an external ear infection (otitis externa) rather than acute otitis media.

B. Fullness in the ear and a clogged sensation might be experienced in acute otitis media, but it usually occurs with systemic signs of infection such as fever and pain.

C. Edema and erythema of the external canal only would indicate an external ear infection (otitis externa), not otitis media, which affects the middle ear.

D. Pulling on the affected ear, acute onset of fever, and otalgia (ear pain) are classic signs of acute otitis media. Children often pull or tug at the affected ear in response to pain.

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Naxlex Comprehensive Predictor Exams

The primary health care provider prescribes patching for a child with amblyopia of the right eye, and the nurse instructs the parent regarding this procedure. What would the nurse include in the instructions?

Correct Answer is B

Explanation

A nurse is caring for a child who has acute otitis media. Which of the following classic assessment findings should the nurse expect?

Correct Answer is D

Explanation

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