A nurse is caring for a 6-week-old infant.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
Condition Most Likely Experiencing
- Pyloric stenosis causes projectile vomiting, dehydration, and hunger.
- Cystic fibrosis causes chronic respiratory infections, steatorrhea, and failure to thrive.
- The condition that the infant is most likely experiencing is congestive heart failure, which can cause poor weight gain, tachypnea, decreased appetite, and periorbital edema.
- Respiratory syncytial virus bronchiolitis causes wheezing, coughing, and respiratory distress.
Actions to Take
- Digoxin is a medication commonly prescribed to manage congestive heart failure in infants by improving cardiac contractility and reducing heart rate.
- Elevating the head of the bed helps reduce venous return to the heart, thereby decreasing preload and relieving symptoms of congestion in congestive heart failure.
- Contact precautions are not indicated for congestive heart failure, but for infections that are transmitted by direct or indirect contact.
- Chest physiotherapy and postural drainage are not indicated for congestive heart failure, but for conditions that cause excessive mucus production and retention.
Parameters to Monitor
- Number of steatorrhea stools is not relevant for congestive heart failure, but for cystic fibrosis or other malabsorption disorders.
- Monitoring intake and output is crucial in assessing fluid balance, especially in congestive heart failure where fluid retention can lead to volume overload.
- Monitoring respiratory status is essential in congestive heart failure to assess for signs of pulmonary congestion and respiratory distress, such as tachypnea, retractions, and crackles.
- Presence of periorbital edema is not a parameter to monitor, but a sign of fluid overload.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Asking the child's parent to leave the room may increase the child's anxiety and make the procedure more traumatic.
B. Performing the procedure in the playroom may not necessarily ensure atraumatic care as the environment may still be unfamiliar and anxiety-provoking for the child.
C. Applying a topical anesthetic cream helps numb the area, reducing the pain and discomfort associated with venipuncture, thus promoting atraumatic care.
D. Explaining the procedure in detail to the child 3 hours prior to the procedure may not be effective in reducing the child's anxiety at the time of the procedure.
Correct Answer is D
Explanation
A. Providing a warm blanket can help alleviate discomfort associated with fever and chills, which are common symptoms of varicella.
B. Koplik spots are seen in measles, not varicella.
C. Aspirin administration is contraindicated in varicella due to the risk of Reye's syndrome. Acetaminophen or ibuprofen may be used for fever.
D. Varicella is spread through respiratory droplets, so standard precautions are typically sufficient. Airborne precautions are necessary to prevent transmission.
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