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A nurse is caring for a 6-week-old infant.

Exhibits

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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. The child's throat pain increasing is expected post-tonsillectomy and can be managed with pain medication. While important to address, it is not the priority in this situation.
B. The child refusing clear liquids may indicate discomfort or difficulty swallowing, but it is not as immediately concerning as other assessment findings.
C. The child crying often may be a response to pain or discomfort but does not indicate a physiological problem requiring immediate attention.
D. The child swallowing frequently is a priority finding because it could indicate bleeding, which is a significant complication after tonsillectomy and requires immediate intervention to prevent further complications or deterioration in the child's condition.

A. A B. B C. C D. D

Correct Answer is {"xRanges":[202.765625,242.765625],"yRanges":[264.609375,304.609375]}

Explanation

A. This is not the site where kolpik spots are located.
B. This is not the site where kolpik spots are located.
C. Koplik spots are small, white or bluish-white spots that appear on the inside of the cheeks, usually opposite the lower molars, in people who have measles. They are a sign of the infection and can be seen one to four days before the skin rash develops. They are surrounded by a red ring and look like grains of salt. Koplik spots are very helpful for diagnosing measles, especially when other diseases have similar symptoms.
D. This is not the site where kolpik spots are located.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a preschool-age child who is in the immediate postoperative period following a tonsillectomy. Which of the following assessment findings is the priority?

Correct Answer is D

Explanation

A nurse is assessing a child who has measles. Which of the following areas should the nurse inspect for Koplik spots? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

Correct Answer is {"xRanges":[202.765625,242.765625],"yRanges":[264.609375,304.609375]}

Explanation

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