An infant with bronchiolitis is taken to the clinic. The infant is congested and febrile with a capillary refill time of 2 seconds.
Which information should the practical nurse (PN) reinforce with the infant's caregiver?
Place infant on back for naps.
Encourage the infant to play.
Limit intake of oral fluids.
Isolate infant from others.
The Correct Answer is D
Choice A rationale
Placing an infant on their back for naps is a critical recommendation to reduce the risk of Sudden Infant Death Syndrome (SIDS), but it is not directly related to managing bronchiolitis symptoms or preventing its spread. While generally good advice, it doesn't address the acute respiratory infection.
Choice B rationale
Encouraging the infant to play might be detrimental during an acute febrile illness like bronchiolitis. Increased physical activity can increase oxygen demand and exacerbate respiratory distress in an infant whose respiratory system is already compromised, potentially worsening their clinical condition.
Choice C rationale
Limiting intake of oral fluids would be counterproductive for an infant with bronchiolitis and fever. Adequate hydration is crucial to thin respiratory secretions, facilitate expectoration, and prevent dehydration, especially with fever, which increases insensible fluid losses. Maintaining hydration supports recovery.
Choice D rationale
Isolating the infant from others is a crucial measure to prevent the spread of respiratory syncytial virus (RSV), the most common cause of bronchiolitis, to susceptible individuals. RSV is highly contagious, and isolation helps protect other children and adults, particularly those with compromised immune systems.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
This schedule is incorrect for pertussis (whooping cough) immunization. Pertussis vaccination, usually as part of the DTaP vaccine, is initiated in infancy and requires multiple doses to build adequate immunity, not just a single dose at 1 year or 6 years of age.
Choice B rationale
This schedule is incorrect and deviates from the standard recommendations for pertussis vaccination. The typical primary series of DTaP vaccination begins earlier in infancy and includes specific booster doses at later ages to maintain protection against the disease.
Choice C rationale
This schedule is incorrect for pertussis immunization. While some vaccinations begin at birth, and boosters are given periodically, the specific timing and frequency for pertussis in this option do not align with the established guidelines for the DTaP or Tdap vaccines.
Choice D rationale
This is the recommended immunization schedule for pertussis, typically administered as part of the DTaP vaccine. The primary series at 2, 4, and 6 months establishes foundational immunity, and boosters at 15-18 months and 4-6 years of age are crucial for maintaining long-term protection against the disease.
Correct Answer is C
Explanation
Choice A rationale
While preventing further disability is a component of care for some progressive conditions, it is not the primary overarching goal for all developmental disabilities. Many developmental disabilities are static and non-progressive, meaning their primary impact is on functional limitations rather than ongoing deterioration. The focus shifts to maximizing existing abilities and potential rather than preventing progression.
Choice B rationale
Meeting rehabilitation needs is a critical aspect of care for children with developmental disabilities, focusing on improving specific skills and functions. However, rehabilitation is a means to an end. The ultimate objective extends beyond just addressing deficits to encompassing the child's holistic development and empowering them to achieve their highest possible level of independence and functioning.
Choice C rationale
The primary goal for a child with a developmental disability is to help them achieve their maximum potential. This encompasses a holistic approach, focusing on enhancing their cognitive, physical, social, emotional, and adaptive skills. It aims to foster independence, improve quality of life, and integrate them into society as much as possible, recognizing their unique strengths and capabilities.
Choice D rationale
Promoting the child's social acceptability, while important for their well-being and integration, is a secondary outcome rather than the primary goal of treatment. The main focus is on the child's individual development and functional abilities. Enhanced social acceptability often naturally follows when a child achieves greater independence and participation in various life domains.
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