A nurse is obtaining vital signs from a 2-month-old infant. The infant's heart rate is 190/min and his temperature is 40° C (104° F). The father asks the nurse why the infant's heart is beating so fast. Which of the following responses by the nurse is appropriate?
"This is within the expected range for your baby."
"The fever is causing an increase in your baby's heart rate."
"As your baby begins to fall asleep. his heart rate will decrease."
"Your baby's heart is beating fast in an attempt to cool down his body."
The Correct Answer is B
In this scenario, the infant has a heart rate of 190/min and a fever of 40°C (104°F). Fever in infants can cause an increase in heart rate, which is a normal physiological response to elevated body temperature. Fever is the body's way of responding to an infection or illness, and it triggers various physiological changes, including an increase in heart rate. This helps the body to circulate blood and deliver immune cells to fight off the infection.
The other options are not accurate or relevant to the infant's current condition:
A. "This is within the expected range for your baby." - A heart rate of 190/min is above the normal expected range for a 2-month-old infant, which is typically between 120 to 160 beats per minute. This response would not address the elevated heart rate and fever.
C. "As your baby begins to fall asleep, his heart rate will decrease." - While heart rate may decrease during sleep, it does not explain the elevated heart rate and fever observed in this situation.
D. "Your baby's heart is beating fast in an attempt to cool down his body." - While tachycardia (fast heart rate) can be associated with increased metabolic demands during fever, the main reason for the increased heart rate in this case is the fever itself, not the body's attempt to cool down. Fever is a response to infection or illness and can cause an increase in heart rate as part of the body's normal immune response.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Hirschsprung disease is a condition where nerve cells are missing from parts of the intestine, leading to problems with bowel movements. The treatment for Hirschsprung disease often involves surgery to remove the affected portion of the bowel and create a temporary ostomy (stoma). An ostomy is an opening in the abdominal wall through which waste material can pass into an external pouch, bypassing the affected section of the intestine.
The correct statement by the parent that indicates an understanding of the teaching is C. The parent is expressing relief that the ostomy is temporary, meaning it is not a permanent situation. This response indicates that the parent has been informed about the nature of the ostomy and its planned duration, which is an essential aspect of preoperative teaching.
Let's go through the other options and explain why they are not the best choices:
A. "I'm glad my child will have normal bowel movements now." This statement is not accurate because, after the initial surgery with the creation of a temporary ostomy, the child will not have normal bowel movements. The ostomy is created to bypass the affected part of the intestine, and the child's bowel movements will be directed through the ostomy until further surgery is performed to reconnect the intestine.
B. "I want to learn how to use my child's feeding tube as soon as possible." While learning how to use a feeding tube may be relevant for certain medical conditions, it is not specifically related to Hirschsprung disease or the planned initial surgery. Hirschsprung disease primarily affects the bowel and its function, not the child's ability to eat.
D. "I want to learn how to empty my child's urinary catheter bag." Hirschsprung disease does not directly impact the urinary system, so there is no specific reason for the parent to learn how to empty a urinary catheter bag in the context of this condition or the planned surgery.
Correct Answer is C
Explanation
A. Gastrointestinal:
Kawasaki disease primarily affects blood vessels, and the gastrointestinal system is not the main target of this condition. While gastrointestinal symptoms can occur as part of the overall inflammatory response, such as abdominal pain, vomiting, or diarrhea, they are not the primary focus of concern in Kawasaki disease. The most critical system to monitor in Kawasaki disease is the cardiovascular system, specifically the coronary arteries.
B. Respiratory:
The respiratory system is not the primary system affected by Kawasaki disease. While respiratory symptoms can occur as part of the overall inflammatory response and fever associated with the disease, such as coughing or runny nose, they are not the main concern in Kawasaki disease. The primary system to monitor in this condition is the cardiovascular system, especially the coronary arteries.
C. Cardiovascular:
This is the correct answer. Kawasaki disease is primarily a vasculitis (inflammation of blood vessels) that affects various blood vessels, including the coronary arteries. The inflammation of the coronary arteries can lead to coronary artery aneurysms and other cardiac complications. Monitoring the cardiovascular system is essential to detect any signs of coronary artery involvement and ensure timely intervention to prevent potential long-term cardiac problems.
D. Integumentary:
The integumentary system (skin) is not the primary focus of Kawasaki disease. While some skin changes can occur during the acute phase of the disease, such as a rash or peeling skin on the hands and feet, these are not the primary concerns. Monitoring the cardiovascular system is critical in Kawasaki disease due to the risk of coronary artery inflammation and potential complications.
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