A nurse is caring for a 6-week-old infant.
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 []
Correct Answers:
Condition Most Likely Experiencing: C
Actions to Take: A, B
Parameters to Monitor: B, C
Rationale:
Condition Most Likely Experiencing
A. Pyloric stenosis causes projectile vomiting, dehydration, and hunger.
B. Cystic fibrosis causes chronic respiratory infections, steatorrhea, and failure to thrive.
C. 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.
D. Respiratory syncytial virus bronchiolitis causes wheezing, coughing, and respiratory distress.
Actions to Take
A. Elevating the head of the bed can help reduce the workload of the heart and improve breathing.
B. Digoxin can increase the contractility of the heart and decrease the heart rate.
C. Contact precautions are not indicated for congestive heart failure, but for infections that are transmitted by direct or indirect contact.
D. 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
A. Number of steatorrhea stools is not relevant for congestive heart failure, but for cystic fibrosis or other malabsorption disorders.
B. Intake and output can indicate fluid balance and renal function.
C. Respiratory status can reflect cardiac function and oxygenation.
D. Presence of periorbital edema is not a parameter to monitor, but a sign of fluid overload.
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Related Questions
Correct Answer is C
Explanation
Rationale:
A. Placing an infant who is 5 months old in a high chair to feed is unsafe because the infant might fall or choke.
B. Positioning a 1-month-old infant supine on a soft mattress increases the risk of sudden infant death syndrome (SIDS).
C. Providing a one-piece pacifier is a safe practice since it prevents the pacifier from breaking apart and causing a choking hazard.
D. Infants should be secured in car seats that are away from airbags. Securing the infant's car seat behind an airbag is dangerous because the airbag could injure or kill the infant in a crash.
Correct Answer is C
Explanation
Rationale:
A. Storing opened vials of insulin for up to 60 days is incorrect. Insulin should be discarded after the manufacturer's recommended expiration date or within 28 days after opening, whichever comes first.
B. Physical therapy is not typically indicated as part of routine care for adolescents with type 1 diabetes mellitus. However, regular physical activity is encouraged for overall health and blood sugar management.
C. Consulting with a nutritionist is important for adolescents with type 1 diabetes mellitus to receive individualized meal planning guidance, carbohydrate counting education, and dietary recommendations to help manage blood sugar levels.
D. Monitoring capillary blood glucose daily is essential for adolescents with type 1 diabetes mellitus, but it is not the only recommendation. Comprehensive diabetes management includes multiple aspects such as insulin therapy, dietary modifications, physical activity, and regular monitoring of blood glucose levels.
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