Phase 2:
A 10-week-old is brought to the emergency department with three days of rhinorrhea, congestion, and cough. He is presenting with mild intercostal retractions, congested cough, HR: 178, RR: 65 breaths/min, his capillary refill is >4 seconds, O2 Sat: 92% on RA, T- 99.2 F, wheezing is heard bilaterally, & mother feels the infant needs help breathing. Unable to stay latched to breast. Restless and has head bobbing. Mother at bedside.
Which complications will the nurse anticipate when caring for this infant?
Dehydration
Pulmonary edema
Infection
Apnea
Respiratory failure
Fatigue
Vomiting
Hypoxia
Correct Answer : A,D,E,F,H
A. Dehydration: The infant is unable to stay latched to breast, indicating poor feeding. Combined with increased work of breathing and restlessness, there's a high risk of inadequate fluid intake, which can quickly lead to dehydration in infants.
B. Pulmonary edema: This is not typically associated with bronchiolitis or viral respiratory infections in infants unless there’s cardiac involvement or fluid overload, which is not indicated here.
C. Infection: While the infant likely already has a viral infection (e.g., RSV), the term “infection” in this context refers to the development of a secondary or worsening infection, which is not an immediate complication unless symptoms progress.
D. Apnea: Young infants, especially those under 3 months, are at risk of apneic episodes when experiencing respiratory infections like bronchiolitis, which this case suggests. Apnea is a known complication, especially in infants under 2–3 months.
E. Respiratory failure: The infant is showing head bobbing, intercostal retractions, RR of 65, and low oxygen saturation — all signs of increasing respiratory distress that, if uncorrected, may progress to respiratory failure.
F. Fatigue: Sustained increased respiratory effort (e.g., tachypnea, retractions, restlessness) can lead to exhaustion, especially in infants with limited energy reserves. Fatigue may worsen breathing and feeding issues.
G. Vomiting: Not reported or directly suggested by the scenario. While some infants may vomit with coughing, it’s not a primary anticipated complication in this case.
H. Hypoxia: With an oxygen saturation of 92% on room air, and clinical signs of distress, hypoxia is already present and must be corrected to prevent further complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E","F","H","I"]
Explanation
Dry lips and mucous membranes can indicate dehydration, which is common in children with diabetes mellitus type 1 (DM1) due to hyperglycemia. Dehydration in DM1 often results from osmotic diuresis, where excess glucose in the urine draws water out of the body, causing significant fluid loss. Immediate follow-up is needed to assess hydration status and possible management of the child's glucose levels and fluid intake.
The presence of enlarged lymph nodes can suggest an underlying infection or immune response. Although lymphadenopathy is commonly associated with infections, it is also important to investigate whether this could be related to diabetic ketoacidosis (DKA), as children with untreated or poorly controlled diabetes can be more prone to infections. This warrants follow-up for possible infection or other causes of lymphadenopathy.
Unexplained weight loss and an appearance of being thin, despite increased appetite (polyphagia), can be an early sign of diabetes type 1. The body begins breaking down fat and muscle tissue for energy when it cannot use glucose properly due to a lack of insulin. Immediate follow-up is necessary to assess blood glucose levels and determine if the child has undiagnosed diabetes.
A fruity or "sweet" odor on the breath, often described as similar to acetone, is a hallmark sign of diabetic ketoacidosis (DKA), a serious and potentially life-threatening complication of uncontrolled diabetes. This requires immediate follow-up as it indicates that the body is burning fat for fuel due to a lack of insulin, resulting in the production of ketones, which are excreted through the breath.
Anxiety can be associated with an underlying medical condition such as diabetes mellitus. Children with uncontrolled diabetes may feel anxious due to fluctuations in blood glucose levels or the physical symptoms associated with hyperglycemia or DKA. It’s important to address the cause of anxiety to ensure the child is receiving the appropriate treatment and emotional support.
A blood pressure of 96/44 mm Hg is on the lower side, and in the context of a child with suspected diabetes, this could suggest a state of dehydration or possible shock, especially if DKA is developing. Blood pressure changes must be followed up immediately to ensure appropriate treatment of dehydration or any circulatory compromise.
Weight: 15.9 kg: The child's weight (15.9 kg) in combination with the other symptoms (e.g., being thin, increased appetite) could indicate that the child is not gaining weight as expected, possibly due to undiagnosed type 1 diabetes. Immediate follow-up is required to assess growth patterns and consider possible conditions like diabetes that could affect normal weight gain.
Correct Answer is B
Explanation
A. Urine creatinine is used to assess kidney function and is not helpful in diagnosing CF.
B. The sweat chloride test is the gold standard for diagnosing cystic fibrosis. Elevated chloride levels in sweat are characteristic of CF.
C. Serum calcium levels are not specific to CF diagnosis.
D. Bronchoscopy is used for assessing airway involvement but is not the primary test for diagnosing CF.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.