Pediatric Nursing – A Case-Based Approach 1st Edition Tagher
Knapp Test Bank
Chapter 1: Bronchiolitis
- Which intervention is appropriate for the infant hospitalized with bronchiolitis?
Position on the side with neck slightly flexed.
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. - 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?
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.
b. Administer antibiotics as ordered.
c. Restrict oral and parenteral fluids if tachypneic.
d. Give cool, humidified oxygen.
a. Reverse isolation
b. Airborne isolation
c. Contact Precautions
d. Standard Precautions - A child has a chronic cough and diffuse wheezing during the expiratory phase of
respiration. This suggests what condition?
ANS: 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. - Which nursing diagnosis is most appropriate for an infant with acute
bronchiolitis due torespiratory syncytial virus (RSV)?
a. Activity Intolerance
b. Decreased Cardiac Output
c. Pain, Acute
d. Tissue Perfusion, Ineffective (peripheral)
ANS. A
Rationale 1: 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.
Rationale 2: 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.
Rationale 3: 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.
Rationale 4: 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.
a. Asthma
b. Pneumonia
c. Bronchiolitis
d. Foreign body in trachea
Global Rationale: 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.
Chapter 2: Asthma
- The nurse is caring for a child hospitalized for status asthmaticus. Which
assessment finding suggests that the childs condition is worsening?
Bradycardia The nurse would assess the child for signs of hypoxia, including restlessness,
fatigue, irritability, and increased heart and respiratory rate. As the child tires from the
increased work of breathing hypoventilation occurs leading to increased carbon dioxide levelsThe nurse would be alert for signs of hypoxia. Thirst would reflect the childs hydration statusBradycardia is not a sign of hypoxia; tachycardia is. Clubbing develops over a period of
months in response to hypoxia. The presence of clubbing does not indicate the childs conditiois worsening. - Which finding is expected when assessing a child hospitalized for asthma?
ANS: C
Wheezing is a classic manifestation of asthma. Inspiratory stridor is a clinical
manifestation of croup. A harsh, barky cough is characteristic of croup.
Rhinorrhea is not associated with asthma.
a. Hypoventilation
b. Thirst
c.
d. Clubbing
ANS: A
a. Inspiratory stridor
b. Harsh, barky cough
c. Wheezing
d. Rhinorrhea - A child has had cold symptoms for more than 2 weeks, a headache, nasal
congestion with purulent nasal drainage, facial tenderness, and a cough that
increases during sleep. The nurse recognizes these symptoms are characteristic
of which respiratory condition?
Allergic rhinitis
ANS: D
Sinusitis is characterized by signs and symptoms of a cold that do not improve
after 14 days, a low-grade fever, nasal congestion and purulent nasal discharge,
headache, tenderness, a feeling of fullness over the affected sinuses, halitosis, and
a cough that increases when the child is lying down. The classic symptoms of
allergic rhinitis are watery rhinorrhea, itchy nose, eyes, ears, and palate, and
sneezing. Symptoms occur as long as the child is exposed to the allergen.
Bronchitis is characterized by a gradual onset of rhinitis and a cough that is
initially nonproductive but may change to a loose cough. The manifestations of
asthma may vary, with wheezing being a classic sign. The symptoms presented in
the question do not suggest asthma. - What is a common trigger for asthma attacks in children?
a. Febrile episodes Exercise is one of the most common triggers for asthma attacks,
particularly in school-age children. Febrile episodes are consistent with other problems, for
example, seizures. Dehydration occurs as a result of diarrhea; it does not trigger asthma
attacks. Viral infections are triggers for asthma. Seizures can result from a too-rapid
intravenous infusion of theophyllinea therapy for asthma.
5.The practitioner changes the medications for the child with asthma to salmeterol
(Serevent). The mother asks the nurse what this drug will do. The nurse explains
that salmeterol (Serevent) is used to treat asthma because the drug produces which
characteristic?
a.
b. Bronchitis
c. Asthma
d. Sinusitis
b. Dehydration
c. Exercise
d. Seizures
ANS: C