A nurse is monitoring an infant who is 6 months old and has sneezing, coughing, nasal congestion, intermittent fever, and apneic spells. The nurse should recognize these findings are consistent with which of the following diagnoses?

Epiglottitis

Bronchiolitis

Influenza

Croup

Answer and Explanation

The Correct Answer is B

Choice A reason: Epiglottitis is a life-threatening condition that causes inflammation and swelling of the epiglottis, the flap of tissue that covers the entrance to the trachea. It can block the airway and cause respiratory distress. The signs and symptoms of epiglottitis include drooling, dysphagia, dysphonia, high fever, and tripod position. Epiglottitis is rare in infants and more common in children aged 2-6 years.

Choice B reason: Bronchiolitis is a viral infection that causes inflammation and mucus production in the bronchioles, the smallest airways in the lungs. It can impair gas exchange and cause respiratory distress. The signs and symptoms of bronchiolitis include sneezing, coughing, nasal congestion, wheezing, tachypnea, retractions, and apneic spells. Bronchiolitis is common in infants and children under 2 years of age, especially during the winter months.

Choice C reason: Influenza is a viral infection that affects the respiratory system. It can cause fever, chills, headache, muscle aches, fatigue, sore throat, cough, and nasal congestion. Influenza can also lead to complications such as pneumonia, otitis media, and sinusitis. Influenza is common in children and adults of all ages, especially during the flu season.

Choice D reason: Croup is a viral infection that causes inflammation and narrowing of the larynx and trachea. It can cause a characteristic barking cough, hoarseness, stridor, and respiratory distress. Croup is common in children aged 6 months to 3 years, especially during the fall and winter months.

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Correct Answer is A

Explanation

Choice A reason: A 13% weight loss is a sign of severe dehydration in infants. Dehydration occurs when the body loses more fluid than it takes in. Acute gastroenteritis can cause vomiting and diarrhea, which can lead to fluid loss and dehydration.

Choice B reason: A bulging anterior fontanel is not a sign of dehydration, but rather a sign of increased intracranial pressure. The anterior fontanel is the soft spot on the top of the infant's head. It should be flat or slightly concave, not bulging or sunken.

Choice C reason: Bradypnea is not a sign of dehydration, but rather a sign of respiratory depression. Bradypnea is abnormally slow breathing, usually less than 12 breaths per minute in infants. Dehydration can cause tachypnea, which is abnormally fast breathing, usually more than 60 breaths per minute in infants.

Choice D reason: A capillary refill of 3 seconds is not a sign of dehydration, but rather a sign of normal perfusion. Capillary refill is the time it takes for the color to return to the nail bed after pressing on it. A normal capillary refill is less than 2 seconds. Dehydration can cause delayed capillary refill, which is more than 2 seconds.

A. Reports of thirst B. Frequent swallowing C. Mouth breathing D. Reports of pain

Correct Answer is B

Explanation

Choice A reason: This statement is incorrect, as reports of thirst are not a manifestation of hemorrhage following a tonsillectomy. Thirst may be caused by dehydration, dry mouth, or fever, which are common after surgery.

Choice B reason: This statement is correct, as frequent swallowing is a manifestation of hemorrhage following a tonsillectomy. Swallowing may indicate that the child is bleeding from the surgical site and trying to clear the blood from the throat. The nurse should inspect the child's mouth and throat for signs of bleeding and notify the provider.

Choice C reason: This statement is incorrect, as mouth breathing is not a manifestation of hemorrhage following a tonsillectomy. Mouth breathing may be due to nasal congestion, pain, or swelling, which are expected after surgery.

Choice D reason: This statement is incorrect, as reports of pain are not a manifestation of hemorrhage following a tonsillectomy. Pain is a normal and expected outcome after surgery and should be managed with analgesics and comfort measures.

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A nurse is monitoring an infant who is 6 months old and has sneezing, coughing, nasal congestion, intermittent fever, and apneic spells. The nurse should recognize these findings are consistent with which of the following diagnoses?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting an infant who has severe dehydration from acute gastroenteritis. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

A nurse is monitoring a child for manifestations of hemorrhage following a tonsillectomy. Which of the following findings is a manifestation of this postoperative complication?

Correct Answer is B

Explanation

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A nurse in a PACU is admitting a client who is postoperative following a tonsillectomy. Which of the following actions should the nurse plan to take to prevent aspiration? Select all that apply

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A nurse is monitoring an infant who is 6 months old and has sneezing, coughing, nasal congestion, intermittent fever, and apneic spells. The nurse should recognize these findings are consistent with which of the following diagnoses?

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?