PEDS CH 1 ?'s
Which nursing diagnosis is most appropriate for an infant with acute bronchiolitis due to respiratory syncytial virus (RSV)? a. Activity Intolerance b. Decreased Cardiac Output c. Pain, Acute d. Tissue Perfusion, Ineffective (peripheral)
A Activity intolerance is a problem because of the imbalance between oxygen supply and demand. Cardiac output is not compromised during an acute phase of bronchiolitis. Pain is not usually associated with acute bronchiolitis. Tissue perfusion (peripheral) is not affected by this respiratory-disease process.
Which intervention is appropriate for the infant hospitalized with bronchiolitis? A. Position on the side with neck slightly flexed. B. Administer antibiotics as ordered. C. Restrict oral and parenteral fluids if tachypneic. D. Give cool, humidified oxygen.
ANS: D Cool, humidified oxygen is given to relieve dyspnea, hypoxemia, and insensible fluid loss from tachypnea. The infant should be positioned with the head and chest elevated at a 30- to 40-degree angle and the neck slightly extended to maintain an open airway and decrease pressure on the diaphragm. The etiology of bronchiolitis is viral. Antibiotics are given only if there is a secondary bacterial infection. Tachypnea increases insensible fluid loss. If the infant is tachypneic, fluids are given parenterally to prevent dehydration.
the nurse is planning care for an infant with bronchiolitis. what is the nurses priority intervention for this child a. position the infant with the head elevated b. monitor intake and output c. assess respiratory status frequently d. incorporate parents into the childs care
C
the nurse is teaching home care to the parents of a child with bronchiolitis. what is the most important information for the nurse to provide a. place the child in a prone position for comfort b. use warm mist to replace insensible fluid loss c. recognize the signs of increasing respiratory distress d. engage the child in many activities to prevent developmental delay
C
An infant is being treated at home for bronchiolitis. what should the nurse teach the parent about home care. select all that apply a. offering small amounts of fluids frequently b. allowing the infant to sleep prone c. calling the clinic if the infant vomits d. writing down how much the infant drinks e. performing chest physiotherapy every 4 hours f. watching for difficulty breathing
a. offering small amounts of fluids frequently f. watching for difficulty breathing
the nurse is caring for a 7mo with bronchiolitis. which symptoms would the nurse expect to find during his assessment. select all that apply a. wheezing b. rr of 46 c. HR of 128 d. RR of 68 e. hr of 82 f. poor feeding
a. wheezing c. HR of 128 d. RR of 68 f. poor feeding
the nurse in the ER is caring for a toddler with dx of bronchiolitis. which sign/symptom should this nurse anticipate during his assessment. select all that apply a. heart rate of 157 b. temp of 101.8 c. subcostal retractions d. poor feeding e. diarrhea
c. subcostal retractions d. poor feeding
3. A child has a chronic cough and diffuse wheezing during the expiratory phase of respiration This suggests what condition? A. Asthma B. Pneumonia C. Bronchiolitis D. Foreign body in trachea
A Asthma may have these chronic signs and symptoms. Pneumonia appears with an acute onset, fever, and general malaise. Bronchiolitis is an acute condition caused by respiratory syncytial virus. Foreign body in the trachea occurs with acute respiratory distress or failure and maybe stridor.
a nurse is explaning bronchioltis to the parents of an infant admitted with the condition. which is the best information for the nurse to provide a. it is a seasonal viral illness that causes inflammation and obstruction of the small airways b. causes decreased mucus secretion which causes air trapping and lobular collapse c. affects premature infants because they lack surfactant d. caused by a bacteria that causes epithelial necrosis and damage to the cilia
A
the nurse is planning care for an infant with bronchiolitis who requires monitoring for dehydration. what is the most important intervention for the nurse to provide a. daily weight b. blood levels every 4 hours c. urinalysis every 8 hours d. weighing each diaper
A
2. An infant with bronchiolitis is hospitalized. The causative organism is respiratory syncytial virus (RSV). The nurse knows that a child infected with this virus requires what type of isolation? A. Reverse isolation B. Airborne isolation C. Contact Precautions D. Standard Precautions
ANS: C RSV is transmitted through droplets. In addition to Standard Precautions and hand washing, Contact Precautions are required. Caregivers must use gloves and gowns when entering the room. Care is taken not to touch their own eyes or mucous membranes with a contaminated gloved hand. Children are placed in a private room or in a room with other children with RSV infections. Reverse isolation focuses on keeping bacteria away from the infant. With RSV, other children need to be protected from exposure to the virus. The virus is not airborne.
a nurse is teachign parents of an infant with bronchiolitis how to bulb suction. which statement should be included a. feed the infant 20 minutes prior to stuctioning b. place the infant in a head down position c. suciton as often as the infant seems to need it d. repeat the suctioning process several times until most of the mucus is removed
D
in preparation for discharge, the nurse teaches the mother of an infant diagnosed with bronchiolitis about the condition and its treatment. which statement by the mother indicates successful teaching a.i need to be sure to take my childs temperature every day b. i hope i do not get a cold from my child c. next time my child gets a cold i need to listen to his chest d. i need to wash my hands more often
D
