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 B
Explanation
A. Administering vaccines prior to discharge may not be appropriate for a child with neutropenia as they have a compromised immune system, and live vaccines should be avoided.
B. Avoiding raw fruits and vegetables in the child's diet is essential because raw produce may harbor bacteria that could potentially lead to infections in a child with neutropenia. Cooked fruits and vegetables are safer options.
C. Bathing the child every other day may be appropriate to maintain cleanliness, but it is not specifically related to neutropenia management.
D. Obtaining the child's rectal temperature once daily is important for monitoring for fever, which can be a sign of infection in a neutropenic child. However, dietary precautions to prevent bacterial exposure are more directly related to managing neutropenia.
Correct Answer is C
Explanation
A. Low hemoglobin indicates anemia, which is a common side effect of leukemia and its treatment, so it does not necessarily indicate treatment effectiveness.
B. Platelet count within normal range is a positive sign, but it does not directly indicate the effectiveness of treatment for leukemia.
C. Normalization of the RBC count indicates bone marrow recovery, suggesting treatment effectiveness in acute lymphoblastic leukemia.
D. Elevated WBC count is expected in leukemia and may not necessarily indicate treatment effectiveness.
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