The nurse is caring for a 10-month-old infant diagnosed with respiratory syncytial virus (RSV) bronchiolitis. Which interventions should be included in the child's care? (Select all that apply.).
Institute cluster care to encourage adequate rest.
Administer cough syrup.
Administer antibiotics.
Encourage infant to drink 8 ounces of formula every 4 hours.
Place on noninvasive oxygen monitoring.
Correct Answer : A,E
The correct answers are choices A and E: Institute cluster care to encourage adequate rest and Place on noninvasive oxygen monitoring.
Choice A rationale:
Institute cluster care to encourage adequate rest. This is a correct choice. Cluster care involves grouping nursing interventions together to minimize disruptions to the child's rest. Adequate rest is crucial for the healing process in infants with respiratory syncytial virus (RSV) bronchiolitis.
Choice B rationale:
Administer cough syrup. This choice is incorrect for RSV bronchiolitis. Cough syrup is not recommended for infants with bronchiolitis. RSV primarily affects the lower respiratory tract and can cause airway inflammation, making cough syrup potentially ineffective and unnecessary.
Choice C rationale:
Administer antibiotics. This choice is incorrect for RSV bronchiolitis. RSV is a viral infection, and antibiotics are ineffective against viruses. Antibiotics should only be used when there is a bacterial infection or a clear indication.
Choice D rationale:
Encourage infant to drink 8 ounces of formula every 4 hours. This choice is not the best approach for managing RSV bronchiolitis. Infants with RSV may experience decreased appetite due to respiratory distress. Smaller, more frequent feedings are often recommended to prevent overfeeding and aspiration.
Choice E rationale:
Place on noninvasive oxygen monitoring. This is a correct choice. RSV bronchiolitis can cause respiratory distress and compromise oxygenation. Noninvasive oxygen monitoring helps assess the child's oxygen levels and aids in determining the need for supplemental oxygen therapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D. Epiglottitis.
Choice A rationale:
Laryngotracheobronchitis (LTB) is a viral infection commonly known as "croup." While it can cause airway inflammation and respiratory distress, it is usually not considered a medical emergency. LTB is characterized by barking cough, stridor, and hoarseness. It typically responds well to supportive care, humidity, and sometimes oral corticosteroids.
Choice B rationale:
Spasmodic croup is another type of viral croup, often triggered by allergies or irritants. It is characterized by sudden onset of symptoms, usually at night, including stridor and a barking cough. While it can be distressing, it is generally not considered a medical emergency. It usually responds to humidity and sometimes oral corticosteroids.
Choice C rationale:
Laryngitis involves inflammation of the larynx and is often caused by viral infections or excessive voice use. While it can lead to hoarseness and voice changes, it does not typically cause severe respiratory distress and is not considered a medical emergency. Resting the voice and staying hydrated are common interventions.
Choice D rationale:
Epiglottitis is a potentially life-threatening condition that causes inflammation of the epiglottis, a flap of tissue that prevents food from entering the windpipe during swallowing. It can rapidly progress to airway obstruction and respiratory failure. Children with epiglottitis often assume a "tripod" position, leaning forward to maintain an open airway. Immediate medical intervention, including securing the airway and administering antibiotics, is crucial.
Correct Answer is D
Explanation
The correct answer is choice D. It is a belief common at this age.
Choice A rationale:
The statement does not suggest a failed attempt to develop a conscience. The scenario described is more related to the cognitive development of an 8-year-old child. Children at this age often have magical thinking and may interpret events, such as illness, as punishments for perceived wrongdoing. This is a normal aspect of their cognitive development rather than a reflection of a failed attempt to develop a conscience.
Choice B rationale:
While beliefs about punishment and consequences are present in many religions, the scenario is not about a general religious belief but rather a specific belief held by the individual child. This belief is reflective of the child's cognitive understanding and not necessarily a religious teaching common to most religions.
Choice C rationale:
The belief is not necessarily suggestive of excessive family pressure. While family dynamics can influence a child's beliefs and behaviors, the scenario describes a typical cognitive developmental stage where children are still learning to differentiate between reality and their own thoughts, leading to magical thinking and unique interpretations.
Choice D rationale:
The belief is indeed common at this age. During middle childhood, children often exhibit concrete operational thinking, which includes a tendency to interpret events in a self-centered and concrete manner. Beliefs like the one described in the scenario, where the child connects her illness to perceived bad behavior and potential consequences, are characteristic of this developmental stage.
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