The nurse is providing care to a 4-month-old infant in the emergency department. Upon assessment, the infant is noted to be experiencing tachypnea, wheezing, retractions, and nasal flaring. The infant has large amounts of nasal drainage. The infant is irritable, and the pulse ox reading is currently at 85% on room air. The parents state the symptoms have been consistent for about two days, but they brought the child in due to concerns for dehydration with decreased milk intake. Which diagnosis does the nurse anticipate for this infant?
Pneumonia
Active pulmonary tuberculosis
RSV
Croup
The Correct Answer is C
Choice A reason: Pneumonia could present with these symptoms, but it is less likely in this case due to the specific combination of symptoms described.
Choice B reason: Active pulmonary tuberculosis is less common in infants and does not typically present with these acute symptoms.
Choice C reason: This is the correct choice. The symptoms described are characteristic of Respiratory Syncytial Virus (RSV), especially in infants.
Choice D reason: Croup could cause some of these symptoms, but it is more commonly associated with a distinctive barking cough and stridor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Developing friendships is important, but it is not as critical as walking in the early stages of a toddler's development.
Choice B reason: This is the correct choice. Walking is a significant developmental milestone for toddlers and is essential for their physical autonomy.
Choice C reason: Self-feeding is an important skill, but it typically develops after the child has learned to walk.
Choice D reason: Potty-training is a key milestone, but it usually occurs after the child has achieved the ability to walk.
Correct Answer is D
Explanation
Choice A reason: A high-pitched cry can be a sign of distress in an infant, but it is not a specific indicator of increased intracranial pressure. It could be due to a variety of reasons, including discomfort, hunger, or other forms of distress.
Choice B reason: Decreased lower extremity movement could be a sign of a neurological issue, but it is not a direct indicator of increased intracranial pressure. It would require further evaluation to determine the cause.
Choice C reason: Excessive wet diapers are not typically associated with increased intracranial pressure. This symptom could be related to other conditions such as diabetes insipidus or excessive fluid intake.
Choice D reason: This is the correct choice. A bulging fontanel when crying is a classic sign of increased intracranial pressure in an infant. The fontanel, or soft spot on the baby's head, can bulge when there is increased pressure within the skull. This should be promptly evaluated by a healthcare professional.
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