119 exam 2

10) Which population should the nurse assigned to care for pediatric clients recognize as having the highest risk of hospitalization due to RSV? A) Alaskan Native infants B) African American infants C) Native American infants D) Asian American infants

A

2) The nurse is analyzing data collected after assessing a child with a congenital heart defect that decreases pulmonary blood flow. Which nursing diagnosis would be applicable for this client? A) Acute Pain B) Ineffective Breathing Pattern C) Decreased Cardiac Output D) Excess Fluid Volume

C) Decreased Cardiac Output

clinical manifestations of CHD

murmurs, exercise intolerance, chest pain, dysrhythmias, syncope

14) The nurse is providing care to a 7-month-old child hospitalized with RSV/bronchiolitis. The nurse can expect to provide client teaching to the parents about which medication? A) Corticosteroids B) Nebulized epinephrine C) Antibiotics D) Nebulized hypertonic saline

D) Nebulized hypertonic saline Nebulized hypertonic saline is used to promote mucociliary clearance in hospitalized clients with RSV/bronchiolitis. Nebulized epinephrine and corticosteroids are no longer recommended for clients with RSV/bronchiolitis. Because RSV is a virus, antibiotics should not be used.

when discussing nutrition with lisa and her family, the nurse recommends continued supplementation of vitamins AEDK because:

Uptake of fat soluble vitamins is decreased in CF.

what teaching can a nurse provide for a CF patient?

administer pancreatic enzymes with meals and snacks high calorie, high protein meals increase fluid intake aerobic activity encouraged

what vitamins should a CF patient supplement in their diet? why?

A, D, E, K, fat-soluble vitamins are not retained adequately in CF patients since they excrete fat in their stools

15) How does a brainstem abnormality contribute to the risk of SIDS when an infant is placed on his stomach to sleep? A) It decreases the infant's arousal and head turning responses during times of asphyxia. B) It decreases the infant's respiratory drive during NREM sleep. C) It increases periods of apnea, resulting in hypoxia and unconsciousness. D) It increases the risk of aspiration and airway obstruction.

Answer: A Explanation: A) A brainstem abnormality, when combined with a stressor such as sleeping in the prone position in a child in the first 6 months of life, will often result in SIDS due to a decreased arousal and head turning response during times of asphyxia. A brainstem abnormality does not decrease the respiratory drive during NREM sleep, increase periods of apnea, or increase the risk of aspiration and airway obstruction.

10) A nurse is preparing to educate a group of parents on sudden infant death syndrome (SIDS). Which variables should the nurse highlight as contributing to increased risk of SIDS? Select all that apply. A) Prone sleeping B) Side sleeping C) Loose bedding D) Bed sharing E) Supine sleeping

Answer: A, B, C, D Significant stressors contributing to SIDS are prone or side sleeping, loose bedding, and bed sharing. Infants in the prone or side-lying positions are vulnerable because the brainstem abnormality compromises their protective reflexes, such as arousal and head turning, when experiencing asphyxia. Supine sleeping is a method to decrease the risk for SIDS.

8) Which best describes how congenital defects are categorized? A) By the severity of defect B) By the pathophysiology and hemodynamics of defect C) By the location of defect D) By the infant's age when the defect was diagnosed

B) By the pathophysiology and hemodynamics of defect

Lisa, age 7 years, has CF. She lives with both parents and a 4-year-old sister who also has CF. Lisa's mother tearfully tells the nurse that she is pregnant and worried that this child will also have CF. Based on the nurse's knowledge of genetics and CF, the nurse understands that A) CF is not an inherited disease B) CF can be diagnosed prenatally C)There is a 50% chance that the child will be affected D) There is a 25% chance that the child will be affected

B) CF can be diagnosed prenatally even if both parents are carriers of the CF gene, te fetus only has a 25% chance of being born with CF as it is an autosomal recessive genetic disorder. CF can be detected prenatally

14) The nurse is caring for an adult client who was diagnosed with a congenital heart defect as a child, which was later repaired with surgery. Which common complication of a heart defect should the nurse monitor that the client may still be at risk for? A) Deep vein thrombosis B) Endocarditis C) Atherosclerosis D) Shock

B) Endocarditis Common complications of congenital heart defects that develop during adulthood include dysrhythmias, endocarditis, stroke, heart failure, pulmonary hypertension, and heart valve problems. Congenital heart defects do not normally cause deep vein thrombosis, atherosclerosis, or shock.

7) The nurse is providing teaching to the client who is pregnant and has cystic fibrosis. The nurse should explain that the client is at increased risk for which condition? A) Emergency delivery B) Gestational diabetes C) Placenta previa D) Spontaneous abortion

B) Gestational diabetes Because of changes in the secretion of insulin in many clients with cystic fibrosis, pregnant women who do not already have diabetes are at increased risk of developing gestational diabetes during pregnancy. Many clients are able to have a natural birth, so planning ahead for an emergency delivery is not necessary. Cystic fibrosis does not increase the client's risk of spontaneous abortion or placenta previa.

9) The nurse is evaluating care provided to a new mother whose infant is at risk for sudden infant death syndrome (SIDS). Which statement by the mother indicates teaching has been effective? A) I need to purchase loose-fitting sheets and blankets for the bed. B) I plan to quit smoking. C) I will place my baby in a side-lying position for sleep. D) I will bottle-feed my baby since breastfeeding is a risk factor for SIDS.

B) I plan to quit smoking.

4) The nurse is providing parenting teaching regarding reducing the risk of sudden infant death syndrome (SIDS). Which teaching point is a priority for the nurse to include? A) Instruct on side-lying and face-down positions when in the crib. B) Instruct on face-up position when in the crib. C) Ensure adequate nutritional intake for the mother and newborn. D) Encourage good hand washing.

B) Instruct on face-up position when in the crib.

The nurse is planning care for a child with respiratory syncytial virus (RSV) bronchiolitis. Which interventions should the nurse include in the child's plan of care to address the nursing diagnosis Impaired Gas Exchange? Select all that apply. A) Weigh daily. B) Monitor vital signs and pulse oximetry. C) Administer oxygen as prescribed. D) Weigh diapers. E) Provide frequent rest periods.

B) Monitor vital signs and pulse oximetry. C) Administer oxygen as prescribed. Interventions appropriate for the client with the nursing diagnosis of Impaired Gas Exchange due to RSV bronchiolitis include monitoring vital signs, pulse oximetry, and breathing pattern, and administering oxygen. Daily weight would be appropriate for the nursing diagnosis of Impaired Nutrition: Less than Body Requirements. Weighing diapers would be appropriate for the nursing diagnosis of Fluid Volume Deficit. Providing frequent rest periods would be appropriate for the nursing diagnosis of Activity Intolerance.

4) The nurse provides discharge instructions to the parents of a child recovering from surgery to repair a congenital heart defect. What statement indicates that teaching has been effective? A) Our child should be restricted in play and activity for at least 6 months. B) Our child will need to take antibiotics prior to having dental surgery. C) Fluids should be restricted to maximize lung function. D) Our child should not return to normal activities for at least 2 years.

B) Our child will need to take antibiotics prior to having dental surgery.

6) A baby will be having surgery to correct a congenital heart defect. On which topic should the parents be instructed regarding the care of the child before surgery? A) Restricting immunizations until after the surgery B) Preventing exposure to infection C) Implementing no particular precautions D) Restricting fluids for a week before the surgery

B) Preventing exposure to infection

1) The mother of a 5-month-old baby, who attends daycare, is concerned because the child has developed a runny nose, cough, and low-grade fever over the last few days. These symptoms are consistent with which condition? A) Meningitis B) Respiratory syncytial virus (RSV) bronchiolitis C) Bronchitis D) The common cold

B) Respiratory syncytial virus (RSV) bronchiolitis The typical clinical presentation of respiratory syncytial virus (RSV) bronchiolitis in otherwise healthy children begins 3-5 days after exposure to the virus. The early signs of a mild infection include rhinorrhea or a runny nose, cough, irritability, and a low-grade fever for 1-3 days. A fever is not associated with the common cold. A runny nose and cough are not symptoms associated with meningitis. Bronchitis has a distinctive cough and may or may not be associated with a fever.

13) The primary cells involved in infection by respiratory syncytial virus (RSV) are the A) smooth muscle cells in the bronchi and bronchioles. B) granular pneumonocytes in the alveoli. C) squamous epithelial cells of the bronchioles and alveoli. D) macrophages and monocytes of the bronchioles and alveoli.

C Respiratory syncytial virus infects the squamous epithelial cells of the bronchioles and alveoli. It does not infect smooth muscle cells, granular pneumonocytes (the surfactant-secreting cells), or the macrophages and monocytes.

2) The nurse is instructing new parents on ways to decrease the risk of sudden infant death syndrome (SIDS) with their newborn son. What should be included in these instructions? Select all that apply. A) There is nothing that can be done, so requirements for toys and bedding are of no consequence. B) Instruct that it is more common in babies from ages 6 months to 18 months. C) Avoid placing the baby in the prone or side-lying position for sleep. D) Remind the parents that the syndrome is more common in females than males, and that they have a male child. E) Do not smoke near the child and reduce all exposure to secondhand smoke.

C) Avoid placing the baby in the prone or side-lying position for sleep. E) Do not smoke near the child and reduce all exposure to secondhand smoke.

The nurse is providing care to a client diagnosed with respiratory syncytial virus (RSV) bronchiolitis. Which assessment finding indicates that treatment has been effective? A) Client ingesting small amounts of clear fluids when encouraged B) Client resting in bed with limited interest in play or activities C) Client respiratory rate within normal limits for age D) Client coughing copious amounts of green sputum and requires occasional suctioning

C) Client respiratory rate within normal limits for age Evidence that care is effective would include normal rate, rhythm, and quality of the breathing patterns for the client's age. The client who is resting in bed with limited interest in play or activities is not demonstrating an improvement in respiratory status. The client who is ingesting small amounts of fluids might still be experiencing thickened secretions. If the client is coughing copious amounts of green sputum and requiring occasional suctioning, the interventions have not been effective, as the child still needs assistance with clearing the airway.

Lisa's father calls the clinic and tells the nurse that Lisa (with CF) "seems very sick." Lisa's father describes her symptoms as "breathing very fast, fast heart rate, short of breath, pale, and color is bluish. The nurse recognizes these symptoms as

Suggestions of a pneumothorax. Damage to the structures of the respiratory system can result in inflammation of cyst development. A pneumothorax can develop if the cyst ruptures.

Pressures in fetal circulation are higher in the lungs and right side of the heart, true or false?

TRUE; In fetal circulation, the right side of the heart has higher pressures than the left side of the heart. This pressure difference allows the shunts to remain open. In postnatal circulation, when the baby takes its first breath, pulmonary resistance decreases, and blood flow through the placenta ceases.

9) The nurse is caring for a child who has just been diagnosed with an atrial septal defect (ASD). Which manifestations would the nurse expect upon assessment? Select all that apply. A) Pulmonary artery hypotension B) Midsystolic murmur at lower right sternal border C) Mitral valve regurgitation with cleft on mitral valve D) S1 heart tone may be split due to forceful left ventricular contraction E) Congestive heart failure

CE ASD occurs when there is an opening in the atrial septum, permitting left-to- right shunting of blood. Midsystolic murmur may be auscultated at the lower left sternal border due to increased blood flow across the tricuspid valve. Mitral valve regurgitation may occur with a cleft on the mitral valve. S1 heart tones may be split due to forceful right ventricular contraction. Finally, pulmonary artery hypertension and congestive heart failure may occur.

A defect in what gene causes Cystic fibrosis

CFTR gene

13) A nurse is preparing to educate a group of parents on sudden infant death syndrome (SIDS). Which intervention is appropriate to decrease an infant's risk for SIDS? A) Using firm bedding B) Ensuring the room temperature is at least 80°F at all times C) Recommending bed sharing D) Placing the infant in a prone position for sleeping

FIRM BEDDING

What food should be avoided for SIDS prevention

HONEY ; spores avoid if under 1 yo

The pulmonary problems associated with CF are:

Increased viscosity of bronchial mucus The genetic mutation associated with CF caused the production of thick mucus that occluded respiratory passes and provides an ideal environment for bacterial growth.

5) The nurse is caring for a premature infant diagnosed with patent ductus arteriosus (PDA). Which medication should the nurse anticipate administering to this client? A) Indomethacin B) Propranolol C) Antibiotics D) Prostaglandin E1

Indomethacin

1) The pediatric nurse is providing education to a new mother regarding ways to decrease the risk of sudden infant death syndrome (SIDS). Which statement by the nurse is appropriate?

It is recommended that you place your baby on his back for sleep

risk factors for congenital heart defects

Maternal rubella, Type I DM, ETOH, PKU, hypercalcemia, drugs and heredity

ductus arteriosus

connecting the pulmonary artery directly to the ascending aorta

foramen ovale

connects the two atria in the fetal heart, bypassing the lungs, allowing oxygenated blood to go to the left atrium

ductus venosus

connects the umbilical vein to the inferior vena cava, bypassing the liver

prostaglandins

maintain fetal circulation, by keeping PDA open to allow blood flow

fetal echocardiogram

test to see if there is a heart defect BEFORE birth; ultrasound

a nurse is admitting a child who has cystic fibrosis, what medications can the nurse expect to include in the plan of care (select all that apply) tobramycin loperamide fat-soluble vitamins albuterol dornase alfa

tobramycin fat-soluble vitamins albuterol dornase alfa

what is the most common congenital heart defect?

ventricular septal defect

What findings are expected in a cystic fibrosis patient? -wheezing -clubbing -barrel chest -thin, watery mucus -rapid growth spurts

-wheezing -clubbing -barrel chest

11) The student nurse attends a workshop on culture and diversity with regard to sudden infant death syndrome (SIDS) and is now aware that the rate of occurrence is highest among which group of infants? A) American Indians B) Caucasians C) Asians D) Hispanics

A) American Indians

1) The ion that cannot be regulated properly in clients with cystic fibrosis is A) chloride. B) sodium. C) calcium. D) potassium.

A) Cystic fibrosis stems from dysfunction of the CFTR protein, which controls movement of chloride into and out of cells. This may also affect transport of sodium in the form of sodium chloride, but the primary ion affected is chloride. Regulation of calcium and potassium is not affected in cystic fibrosis.

Which prevention strategies would be the most beneficial for the nurse to discuss with the parents of a child who has had repeated admissions for respiratory syncytial virus (RSV) bronchiolitis? Select all that apply. A) Do not smoke, and avoid all secondhand smoke around the child. B) Practice frequent hand washing. C) Encourage physical activity and play. D) Consider alternatives to sending the child to daycare. E) Ensure an adequate nutritional intake.

A) Do not smoke, and avoid all secondhand smoke around the child. B) Practice frequent hand washing. D) Consider alternatives to sending the child to daycare. Exposure to cigarette smoke and attending daycare are both risk factors for RSV/bronchiolitis. The nurse should discuss with the parents smoking cessation and alternative methods of childcare. Practicing frequent hand washing is a primary prevention method for RSV, so this should be practiced by the parents. Nutritional intake and physical activity are good for maintaining general health, but they are not specific for preventing RSV/bronchiolitis.

3) The nurse is planning care for a pediatric client recovering from surgery to repair a congenital heart defect. Which intervention should the nurse include to support the client's fluid status? A) Encourage oral intake of fluids when permitted. B) Limit oral and intravenous intake of fluids. C) Continue normal saline administration even after oral intake is normal. D) Convert the intravenous line to a saline lock immediately after surgery.

A) Encourage oral intake of fluids when permitted.

12) During what period of gestation do congenital heart defects usually develop? A) First 8 weeks of gestation B) Second trimester C) Third trimester D) Last 4 weeks of gestation

A) First 8 weeks of gestation Most congenital heart defects develop during the first 8 weeks of gestation. They are usually the result of combined genetic and environmental factors.

The clinic nurse is educating a group of new moms on the risk factors and prevention of respiratory syncytial virus (RSV). What should the nurse stress as the best way to prevent RSV? A) Hand washing B) Monitoring temperature C) Administering antibiotics D) Limiting fluid intake

A) Hand washing The best way to prevent RSV is through good hand hygiene and infection- control measures. Monitoring temperature would not prevent infection but would be appropriate for monitoring infection. Administering antibiotics is usually ordered by the physician when a bacterial infection is suspected, not a viral infection. There is no indication of the need to limit fluids, which could potentially produce other complications.

7) The nurse is placing a newborn baby in the nursery crib with the babys back down. The mother tells the nurse that she doubts the baby will be able to sleep that way, as all the family members sleep on their stomachs. Which action by the nurse is appropriate? A) Instruct the mother that placing the baby on the back will reduce the risk of sudden infant death syndrome (SIDS) and it will not interfere with sleep. B) Place the baby on the stomach. C) Suggest the mother place the baby on the stomach when at home. D) Instruct the mother that babies do not really care in which position they are in but placing on the back is easier to provide care.

A) Instruct the mother that placing the baby on the back will reduce the risk of sudden infant death syndrome (SIDS) and it will not interfere with sleep.

1) The mother of a baby born with a congenital heart defect is upset, as no one else in the family has been born with this condition. To determine the cause of the defect, which question is appropriate for the nurse to ask the mother? A)"Did you consume any alcohol before you knew you were pregnant?" B) "Is there a history of diabetes in your family?" C) "Was the baby's father exposed to any toxins in the work environment?" D) "Do you have a history of hypertension?"

A) Most congenital heart defects occur during the first 8 weeks of pregnancy and are a combination of environmental and genetic factors. Fetal exposure to alcohol is one of the greatest factors for the development of these defects. Asking the mother if she consumed alcohol before she was aware that she was pregnant is an appropriate question when determining the cause of the heart defect. A history of hypertension will not cause a fetus to develop a congenital heart defect. The father's exposure to toxins in the work environment is not known to cause congenital heart defects of children. Maternal diabetes can impair fetal heart development, but a family history of diabetes is not known to cause congenital heart defects.

11) The nurse is caring for an infant diagnosed with hypoplastic left heart syndrome. The client has recently been scheduled for surgery to repair the defect. Which procedure does the nurse anticipate needing to provide client teaching about to the clients family? A) Norwood procedure B) Jatene procedure C) Rastelli procedure D) Damus-Kaye-Stansel procedure

A) Norwood procedure Hypoplastic left heart syndrome is repaired using the Norwood, Glenn, and Fontan procedures, depending on the childs age. The Jatene procedure and the Damus-Kaye- Stansel procedure surgically repair the Transposition of Great Arteries (TGA). The Rastelli procedure is used to repair TGA with ventricular septal defect and pulmonary stenosis.

11) The nurse working in the emergency department (ED) is assessing an infant client. Which findings does the nurse anticipate in a child diagnosed with respiratory syncytial virus (RSV)? Select all that apply. A) Rhinorrhea B) Irritability C) Grunting D) Bradypnea E) Tachypnea

A) Rhinorrhea B) Irritability C) Grunting E) Tachypnea

5) The nurse is planning care for a baby born to a mother who smoked during the pregnancy. The mother states that she believes in bed sharing. Which nursing diagnosis would be appropriate for this baby? A) Risk for Sudden Infant Death Syndrome (SIDS) B) Readiness for Enhanced Parenting C) Anxiety D) Deficient Knowledge

A) Risk for Sudden Infant Death Syndrome (SIDS)

a nurse is reviewing the diagnostic findings for a preschool age child who is suspected to have CF, which of the following supports the diagnosis? A. sweat chloride: 85 mEq/L B. Increased blood levels of fat soluble vitamins C. 72 hr stool analysis sample indicating hard, packed stools D. Chest X-ray negative for atelectasis

A. sweat chloride: 85 mEq/L

Lisa tells the nurse that she would "like to play soccer like my friends." The nurse's recommendation should be based on knowledge that physical exercise is A. important because it encourages effective breathing. B. important because it stimulates underactive sweat glands. C. contraindicated because it causes coughing. D. contraindicated because it causes forced expiration.

A: increased physical fitness can improve overall health and lung function and increased the need to cough and expectorate mucus. Physical activity can help to loosen mucus and strengthen the respiratory muscles. Participation in regular exercise will improve and maintain muscle strength

12) The nurse is planning care for the parents of an infant who died as the result of sudden infant death syndrome. Which collaborative interventions does the nurse plan for when providing care to these parents? Select all that apply. A) A psychosocial assessment B) A grief counselor referral C) A psychotherapist referral D) A visit from the chaplain E) A respiratory therapist referral

ABCD Collaborative care for the parents may include grief counselors, chaplains and religious leaders, nurses (including school nurses working with older children who lose a sibling), and psychotherapists. In particular, the parents; grief will be acute, and they should receive a psychosocial assessment at each healthcare interaction. A respiratory therapist referral is inappropriate for this situation.

3) When assessing the risk of a newborn for sudden infant death syndrome (SIDS), which are risk factors that the nurse should consider? Select all that apply. A) Race B) Gender C) Father age D) Age E) Eye color

ABD SIDS is most common in American Indians and Alaska Natives, followed by non-Hispanic Blacks, non-Hispanic Whites, Hispanics, and Asian or Pacific Islanders. It is more common in males than in females. SIDS is most common in infants under 6 months of age. Fathers age and infant eye color are not related to the risk of SIDS.

7) The nurse is assessing a toddler diagnosed with tetralogy of Fallot (TOF). Which clinical manifestations does the nurse anticipate during the physical assessment? Select all that apply. A) Palpable thrill in the pulmonic area B) Nail clubbing C) Cough D) Apneic periods E) Knee-chest position

ABE Manifestations of TOF include a palpable thrill in the pulmonic area, clubbing of the fingers due to reduce oxygenation, and the knee-chest position, which the child will perform to decrease the return of systemic venous blood to the heart. A cough and apneic periods are not manifestations of this congenital heart defect.

2) For couples in which both individuals carry one defective CF gene, any offspring from the couple has a ________ percent chance of inheriting two abnormal genes and developing cystic fibrosis. A) 100 B) 75 C) 50 D) 25

Answer: D When both parents are carriers of the CF gene, each conception allows for a 25% possibility that two abnormal genes will be passed to the child, along with a 50% possibility that the child will be a carrier of one CF gene. Each conception also allows for a 25% possibility that the child will not carry the CF gene.

12) The nurse is developing a plan of care for a toddler diagnosed with respiratory syncytial virus (RSV). Which intervention is inappropriate for this client? A) Offer small, frequent meals. B) Encourage to ambulate frequently. C) Encourage oral intake. D) Monitor intake and output.

B It would not be appropriate to encourage frequent ambulation. Nursing interventions should be introduced in an effort to reduce fatigue, such as allowing rest periods. All other interventions are appropriate for this client.

3) Besides the respiratory system, which system would be critical for the nurse to assess in a client recently diagnosed with cystic fibrosis? A) Nervous system B) Gastrointestinal system C) Musculoskeletal system D) Urinary system

B: GI In addition to respiratory alterations, clients with cystic fibrosis often have alterations to the gastrointestinal system. In particular, obstruction of pancreatic ducts by thick mucus impairs the production of pancreatic enzymes that are necessary for food digestion. This results in malnutrition, chronic diarrhea, and impaired insulin production. Cystic fibrosis does not affect the nervous system, musculoskeletal system, or urinary system directly.

4) The nurse is caring for an 18-month-old client who is newly diagnosed with cystic fibrosis. The client is currently hospitalized due to a Pseudomonas aeruginosa infection in the lungs. The vital signs are: P 138, R 43, T 101.3°F, BP 86/40, SpO2 88%. The client is coughing up thick, green mucus. What independent nursing intervention can the nurse implement to improve the client's oxygenation? A) Administration of CFTR modulators B) Percussion and postural drainage C) Nutritional counseling D) Teaching the client to cough into a tissue

B: percussion and postural drainage Percussion and postural drainage are chest physical therapy techniques that the nurse can implement to help clear the client's lungs of mucus, which will improve oxygenation. Administration of CFTR modulators and nutritional counseling are both collaborative interventions. Teaching the client to cough into a tissue is an infection control measure. It will not improve oxygenation compared to any other type of coughing. In addition, the client is likely too young to understand and follow through with this teaching consistently.

5) A 7-year-old client is hospitalized due to complications related to cystic fibrosis. The nurse is responsible for administering medications and performing chest physical therapy. In which order should the nurse perform these actions? A) Place the client in a position for postural drainage B) Administer inhaled albuterol C) Administer inhaled hypertonic saline D) Perform percussion on the client's back and chest E) Administer oxygen by nasal cannula

BCADE Inhaled medications should be administered before placing the client in a position for postural drainage and performing percussion. In particular, albuterol, a bronchodilator, should be administered before chest physical therapy and before other inhaled medications. Therefore, albuterol should be administered first, followed by hypertonic saline. Then chest physical therapy should be performed by first placing the client in a position for postural drainage and then performing percussion on the client's back and chest. After the medications and therapy are completed, administration of oxygen by nasal cannula will be more effective.

The nurse assesses fatigue in an infant with acute bronchiolitis due to respiratory syncytial virus (RSV). Which nursing diagnosis would be most appropriate for the infant? A) Acute Pain B) Ineffective Tissue Perfusion C) Activity Intolerance D) Decreased Cardiac Output

C - activity intolerance

Which is the most appropriate outcome for the nurse to select for a 78-year-old resident of a long-term care facility with regard to preventing RSV? A) The client's airways will remain clear of secretions. B) The client's fluid intake will meet daily requirements of 2000 mL per day. C) The client will demonstrate knowledge of proper hand washing techniques. D) The client will meet daily nutritional needs as provided by a nutritionist.

C The client will demonstrate knowledge of proper hand washing techniques.

An infant with respiratory syncytial virus (RSV) bronchiolitis is prescribed intubation to maintain an adequate airway. Who will the nurse collaborate with to maintain the endotracheal tube and ventilation? A) An advanced practice nurse B) The primary healthcare provider C) A respiratory therapist D) A play therapist

C) A respiratory therapist A) Infants who need endotracheal intubation will be closely cared for by the respiratory therapist. The advanced practice nurse, primary healthcare provider, and play therapist are not responsible for maintaining the client's endotracheal tube and ventilation.

6) A 15-year-old client with cystic fibrosis asks why she has not started her menstrual period yet. Which response by the nurse is correct? A) Usually girls with cystic fibrosis start menstruating earlier than their peers; B) It is normal for girls with cystic fibrosis to start their period at age 16. Just be patient. C) Some girls with cystic fibrosis do not experience menstruation due to nutritional problems. D) Because secretions are thicker in people with cystic fibrosis, your period will be very heavy once it starts.

C) Some girls with cystic fibrosis do not experience menstruation due to nutritional problems. Disease-related nutritional deficiencies may interfere with normal reproductive development, causing some girls with cystic fibrosis to not experience menstruation. They do not usually start menstruating earlier than their peers, nor does their period usually start specifically at age 16. CF affects the thickness of mucus secretions, but it does not affect the thickness of the blood. Therefore, the statement about heavy periods is inaccurate.

The nurse observes a toddler, admitted with possible respiratory syncytial virus (RSV) bronchiolitis, grunting with expiration. Which action by the nurse is appropriate? A) Assist the child to clear the nasal passages. B) Limit fluids. C) Suction the airway to relieve the obstruction. D) Lay the child on his back.

C) Suction the airway to relieve the obstruction. Grunting is seen with partial airway obstruction caused by increased secretions and edema. The nurse should suction the airway to relieve the obstruction. Laying the child on his back will not improve the child's ability to breathe. Fluids should be increased to thin secretions. Assisting the child to clear the nasal passages would be applicable if the child were experiencing rhinorrhea.

The mother of an 8-month-old baby who has developed respiratory syncytial virus (RSV)/bronchiolitis wants to know which factors contribute to the risk of contracting RSV. Which response by the nurse is appropriate? A) There is a higher risk in children who are being breastfed. B) There is no way to avoid the illness. C) There is a higher risk in children who are exposed to secondary cigarette smoke. D) It is seen more frequently in children who do not attend daycare.

C) There is a higher risk in children who are exposed to secondary cigarette smoke. The risk of infection with RSV is higher for infants and toddlers who are not breastfed, live in homes with secondary cigarette exposure, attend daycare, live in crowded conditions, or are socioeconomically disadvantaged. RSV can be avoided by limiting these risk factors.

14) Sudden infant death syndrome is diagnosed A) when an autopsy reveals a brainstem defect. B) when an infant dies after being shaken violently. C) when an autopsy fails to find a cause of death. D) when an infant is found dead in their crib.

C) when an autopsy fails to find a cause of death.

Infant manifestations of CHD

CRITICAL cyanosis rapid breathing grunting FLARED nostrils retractions edema in eyes, legs, abdomen failure to feed - NEURO DELAYS

13) The nurse is caring for a pregnant woman with congenital heart disease. The woman asks if she will be able to have a vaginal delivery. Which answer by the nurse is correct? A) A Cesarean section is preferred because you will lose less blood than with a vaginal birth. B) A Cesarean section is preferred because there is a lower risk of infection than with a vaginal birth. C) A vaginal birth is preferred over a Cesarean section for women who have aortic stenosis. D) A vaginal birth is preferred because there is a lower risk of thrombophlebitis than with a Cesarean section.

D) A vaginal birth is preferred because there is a lower risk of thrombophlebitis than with a Cesarean section. Vaginal delivery is preferable to Cesarean section for most clients with congenital heart defects because they will likely lose less blood with vaginal birth. Risk of wound infection and thrombophlebitis are also concerns with Cesarean birth. Dilated aorta, pulmonary hypertension, and aortic stenosis are contraindications for vaginal delivery.

8) The nurse is providing supportive care for the parents of an infant who died from sudden infant death syndrome (SIDS). Which action by the nurse is appropriate? A) Advising the parents that an autopsy is not necessary B) Refraining from recommending support groups until after the investigation C) Interviewing the parents to determine the cause of the SIDS incident D) Contacting the familys spiritual leader for support

D) Contacting the familys spiritual leader for support

10) The nurse is providing teaching to the parents of a child born with tetralogy of Fallot (TOF). Which statement should the nurse include in her teaching regarding this defect? A) Increased pulmonary blood flow causes symptoms with this disease B) This disease consists of pulmonic stenosis, left ventricular hypertrophy, ventricular septal defect, and an overriding aorta. C) Your child has a decreased amount of red blood cells because of this disease. D) This disease consists of pulmonic stenosis, right ventricular hypertrophy, ventricular septal defect, and an overriding aorta.

D) This disease consists of - pulmonic stenosis - right ventricular hypertrophy - overriding aorta. - ventricular septal defect This disease is also characterized by decreased pulmonary blood flow and polycythemia (increased red blood cells due to hypoxia).

6) The nurse is planning care for a new mother who smoked during the pregnancy and whose sister lost a child to sudden infant death syndrome (SIDS). Which interventions are appropriate for the nurse to include in the plan of care for the new mother and baby? Select all that apply. A) Information on bottle-feeding the infant B) Reasons why the child should sleep with others C) Ages at which the child should receive immunizations D) Using bedding that is firm E) Smoking cessation information

D) Using bedding that is firm E) Smoking cessation information

15) The nurse is assessing an adult client with respiratory syncytial virus (RSV). Which symptom will the nurse expect to assess that is not seen in infants with RSV? A) Rhinorrhea B) Cough C) Apnea D) Headache

D. Headache Rhinorrhea (runny nose) and cough are symptoms that are common to both infants and adults with RSV. Apnea is more commonly seen in infants, not in adults. However, a headache must be reported by the client, which infants are unable to do. Therefore, headaches are more commonly assessed in adults with RSV and not infants.