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 ["A","C","D","E","F"]

Explanation

A. Household smoking increases the risk of otitis media by irritating the respiratory tract and impairing immune function.

B. A history of urinary tract infections is not a risk factor for otitis media.

C. Exposure to illness in daycare centers or schools increases the likelihood of respiratory infections, which can lead to otitis media.

D. Native American ethnicity has a higher incidence of otitis media, likely due to genetic and environmental factors.

E. Absence of breastfeeding increases the risk of otitis media because breastfeeding provides immune protection.

F. Craniofacial anomalies (e.g., cleft palate) increase the risk of otitis media due to poor Eustachian tube function and chronic ear infections.

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

A 4-year-old child is diagnosed with otitis media. The parent asks the nurse about the causes of this illness. Which risk factors would the nurse include in response to this parent? Select all that apply.

Correct Answer is ["A","C","D","E","F"]

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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