A nurse is monitoring an infant who is 3 months old and has sneezing, coughing, nasal congestion, intermittent fever, and apneic spells. These nurse should recognize these findings are associated with which of the following diagnoses?

Epiglottitis

Bronchiolitis

Influenza

Croup

Answer and Explanation

The Correct Answer is B

A. Epiglottitis

Epiglottitis typically presents with rapid onset of severe sore throat, high fever, difficulty swallowing, and drooling due to inflammation and swelling of the epiglottis. It is a medical emergency requiring immediate intervention but is less likely to present with the described symptoms.

B. Bronchiolitis

Bronchiolitis commonly occurs in infants and young children, often during the winter months. It is characterized by symptoms such as coughing, wheezing, nasal congestion, fever, and

respiratory distress. The described symptoms, including coughing, nasal congestion, and intermittent fever, align with bronchiolitis.

C. Influenza

Influenza typically presents with symptoms such as fever, cough, sore throat, body aches, and fatigue. While coughing and fever are common symptoms of influenza, the presence of apneic spells is less typical of influenza and more indicative of lower respiratory tract infections like bronchiolitis.

D. Croup

Croup is characterized by a barking cough, hoarseness, and respiratory distress often accompanied by stridor. While croup shares some symptoms with bronchiolitis, such as coughing, the absence of stridor in the description suggests bronchiolitis as a more likely diagnosis.

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Correct Answer is C

Explanation

A. Discouraging daily fruit juice intakE. While excessive fruit juice intake can contribute to weight gain and dental caries, it's not the priority nursing intervention in this scenario.

B. Increasing the number of breastfeedings: Breastfeeding frequency may be appropriate, but without more information about the child's current feeding patterns and growth trajectory, it's not the priority intervention.

C. Discussing the child's feeding patterns: This is the priority intervention because it allows the nurse to assess the child's current feeding habits, including frequency, duration, and type of feedings, to determine if they are appropriate for the child's growth and development.

D. Talking about solid food consumption: Solid food introduction is typically recommended around 6 months of age, but the priority in this scenario is to assess the current feeding

patterns before discussing solid food introduction.

A. Body weight B. Skin integrity C. Respiratory rate D. Blood pressure

Correct Answer is A

Explanation

A. Body weight: Body weight is the most reliable indicator of fluid loss, as changes in weight directly reflect changes in fluid balance. Monitoring weight is essential for assessing dehydration and guiding fluid replacement therapy.

B. Skin integrity: While changes in skin turgor and skin integrity can be indicators of

dehydration, they are less reliable in infants, especially if they have certain skin conditions or are very young.

C. Respiratory ratE. Although increased respiratory rate can occur as a compensatory mechanism for metabolic acidosis associated with dehydration, it is not as reliable as changes in body weight for assessing fluid loss.

D. Blood pressurE. While blood pressure may be affected by severe dehydration, it is not as sensitive or practical as monitoring body weight for assessing fluid loss in infants.

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A nurse is monitoring an infant who is 3 months old and has sneezing, coughing, nasal congestion, intermittent fever, and apneic spells. These nurse should recognize these findings are associated with which of the following diagnoses?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 6-month-old girl weighs 14.7 lb during a scheduled check-up. Her birth weight was 8 lb. What is the priority nursing intervention?

Correct Answer is C

Explanation

A nurse in an emergency department is caring for an infant who has a 2-day history of vomiting and an elevated temperature. Which of the following should the nurse recognize as the most reliable indicator of fluid loss?

Correct Answer is A

Explanation

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