The nurse is providing care to a 4-month-old infant in the emergency department. Upon assessment, the infant is noted to be experiencing tachypnea, wheezing, retractions, and nasal flaring. The infant has large amounts of nasal drainage. The infant is irritable, and the pulse ox reading is currently at 85% on room air. The parents state the symptoms have been consistent for about two days, but they brought the child in due to concerns for dehydration with decreased milk intake. Which diagnosis does the nurse anticipate for this infant?

Pneumonia

Active pulmonary tuberculosis

RSV

Croup

Answer and Explanation

The Correct Answer is C

Choice A reason: Pneumonia could present with these symptoms, but it is less likely in this case due to the specific combination of symptoms described.
Choice B reason: Active pulmonary tuberculosis is less common in infants and does not typically present with these acute symptoms.
Choice C reason: This is the correct choice. The symptoms described are characteristic of Respiratory Syncytial Virus (RSV), especially in infants.
Choice D reason: Croup could cause some of these symptoms, but it is more commonly associated with a distinctive barking cough and stridor.

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Correct Answer is ["B","E"]

Explanation

Choice A reason: Tripod positioning is a more severe sign, indicating increased work of breathing.
Choice B reason: This is one of the correct choices. Nasal flaring is a mild symptom of respiratory distress, indicating increased effort to breathe.
Choice C reason: Confusion is a more severe symptom, suggesting hypoxia affecting brain function.
Choice D reason: Cyanosis is a severe sign of respiratory distress, indicating poor oxygenation.
Choice E reason: This is one of the correct choices. Tachypnea, or rapid breathing, is a mild symptom of respiratory distress.

A. Limit consumption of green, leafy vegetables. B. Perform passive range of motion exercises. C. Avoid lifting heavy objects. D. Take midodrine as prescribed.

Correct Answer is C

Explanation

Choice A reason: Limiting green, leafy vegetables is not typically necessary for patients with liver disease and esophageal varices unless they are on anticoagulant therapy.
Choice B reason: While passive range of motion exercises are beneficial for maintaining joint mobility, they are not directly related to the prevention of hematemesis.
Choice C reason: This is the correct choice. Lifting heavy objects can increase abdominal pressure and the risk of bleeding from esophageal varices.
Choice D reason: Midodrine is a medication used to treat low blood pressure, not specifically for esophageal varices or hematemesis.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following are mild symptoms of respiratory distress? (Select the two responses that apply)

Correct Answer is ["B","E"]

Explanation

A patient with liver disease and esophageal varices is admitted for an episode of hematemesis. Which patient teaching should the nurse provide prior to discharge?

Correct Answer is C

Explanation

What is the best response by the nurse when the parents ask about the paralysis associated with Guillain-Barré Syndrome, which has affected the respiratory muscles and requires mechanical ventilation for their child?

When developing a plan of care for a hospitalized child, the nurse knows that children in which age group are most likely to view illness as a punishment for misdeeds?

What is the likely result of a child fracturing a bone through a portion of the epiphyseal plate?

The nurse finds that an infant has stronger pulses in the upper extremities than in the lower extremities. Which assessment will the nurse perform next on this infant?

The nurse observes that a client with Parkinson’s disease (PD) has a mask-like face. Which follow-up assessment is most important for the nurse to implement?

What notable sign most likely indicates increased intracranial pressure in an infant?

Which of the following is the best indicator of brain function in a child with a moderate brain injury?

After surgery for the correction of bilateral congenital clubfeet, an infant returns with bilateral long-leg casts. The toes on both feet are edematous, yet there is color, sensitivity, and movement. What is the most appropriate action by the nurse?