2nd Edition by Tagher Knapp
Chapters 1 - 34 | All Chapters
,
,Chaptert1:t Bronchiolitis
1. Whichtinterventiontistappropriatetfort thetinfantthospitalizedtwithtbronchiolitis?
a. Positiontontthetsidetwithtnecktslightlytflexed.
b. Administertantibioticstastordered.
c. Restricttoraltandtparenteraltfluidst ifttachypneic.
d. Givetcool,thumidifiedtoxygen.t
ANSWER:tD
Cool,thumidifiedtoxygentistgiventtotrelievetdyspnea,thypoxemia,tandtinsensibletfluidtlosstfromttachypne
a.tThetinfantt shouldtbet positionedtwithtthetheadtandtchestt elevatedtatt at30-ttot 40-
degreetangletandtthetnecktslightlytextendedt tot maintaintantopentairwaytandt decreasetpressuret ontthetdiap
hragm.tThetetiologytoftbronchiolitististviral.tAntibioticstaretgiventonlytifttheretistatsecondarytbacterialtinf
ection.tTachypneatincreasestinsensibletfluidtloss.tIftthetinfanttisttachypneic,tfluidstaretgiventparenterally
ttot preventtdehydration.
2. Antinfantt withtbronchiolitististhospitalized.tThetcausativetorganismtistrespiratorytsyncytialtviru
st(RSV).tThetnursetknowstthatt atchildtinfectedt withtthist virustrequirestwhatttypet oftisolation?
a. Reversetisolation
b. Airbornetisolation
c. Contactt Precautions
d. StandardtPrecautionst
ANSWER:tC
RSVt isttransmittedt throught droplets.t Int additiont tot Standardt Precautionst andthandt washing,tContactt Pr
ecautionstaretrequired.t Caregiverst musttuset glovest andt gownstwhententeringtthetroom.tCaret isttakent nott
tot touchttheirt ownt eyest ortmucoust membranest withtat contaminatedt glovedt hand.tChildrentaret placedt int
atprivatet roomtort intatroomtwithtothert childrentwithtRSVt infections.
Reversetisolationtfocusestontkeepingtbacteriatawaytfromtthetinfant.tWithtRSV,tothertchildrentneedttotbet
protectedtfromtexposurettotthetvirus.tThetvirustistnottairborne.
3. Atchildthastatchronictcoughtandtdiffusetwheezingtduringtthetexpiratorytphasetoftrespiration.tThist
suggeststwhattcondition?
a. Asthma
b. Pneumonia
c. Bronchiolitis
d. Foreigntbodytinttracheat
ANSWER:tA
Asthmat maythavettheset chronict signstandtsymptoms.t Pneumoniatappearstwithtantacutetonset,t fever,tandtg
eneraltmalaise.tBronchiolitist istantacutetconditiont causedtbytrespiratorytsyncytial
, virus.t Foreigntbodytintthettracheatoccurstwithtacutetrespiratorytdistresstortfailuretandtmaybetstridor.
4. Whichtnursingtdiagnosististmostt appropriatetfortantinfantt withtacutetbronchiolitistduettotresp
iratorytsyncytialtvirust(RSV)?
a. ActivitytIntolerance
b. Decreasedt Cardiact Output
c. Pain,tAcute
d. TissuetPerfusion,tIneffectivet(peripheral)t
ANS.tA
Rationalet1:tActivitytintolerancet istatproblemtbecausetoftthetimbalancetbetweentoxygentsupplyt andtdem
and.tCardiact outputt istnottcompromisedt duringtantacutetphaset oftbronchiolitis.t Paint ist nottusuallytassoci
atedtwithtacutetbronchiolitis.tTissuetperfusiont(peripheral)t istnottaffectedtbyt thistrespiratory-
diseasetprocess.
Rationalet2:tActivitytintolerancet istatproblemtbecausetoftthetimbalancetbetweentoxygentsupplytandtdema
nd.tCardiact outputt istnott compromisedt duringtantacutet phasetoftbronchiolitis.t Paint ist nottusuallytassociat
edtwithtacutetbronchiolitis.tTissuetperfusiont(peripheral)t istnottaffectedtbyt thistrespiratory-
diseasetprocess.
Rationalet3:tActivitytintolerancetistatproblemtbecausetoftthetimbalancetbetweentoxygentsupplyttandtdema
nd.tCardiact outputt istnott compromisedt duringtantacutet phasetoft bronchiolitis.t Paint ist nottusuallytassociat
edtwithtacutetbronchiolitis.tTissuetperfusiont(peripheral)t istnottaffectedtbyt thistrespiratory-
diseasetprocess.
Rationalet4:tActivitytintolerancet istatproblemtbecausetoftthetimbalancetbetweentoxygentsupplytandtdema
nd.tCardiact outputt istnott compromisedt duringtantacutet phasetoftbronchiolitis.t Paint ist nottusuallytassociat
edtwithtacutetbronchiolitis.tTissuetperfusiont(peripheral)t istnottaffectedtbyt thistrespiratory-
diseasetprocess.
GlobaltRationale:tActivitytintolerancetistatproblemtbecausetoftthetimbalancetbetweentoxygentsupplyt
andt demand.tCardiactoutputt istnottcompromisedt duringtant acutetphaset oftbronchiolitis.tPaintistnottusua
llytassociatedtwithtacutetbronchiolitis.tTissuetperfusiont(peripheral)t istnott affectedtbytthistrespiratory-
diseasetprocess.
Chaptert 2:tAsthma
1. Thetnursetistcaringtfortatchildthospitalizedtfortstatustasthmaticus.t Whichtassessmenttfindingtsug
geststthattthetchildstconditiontistworsening?
a. Hypoventilation
b. Thirst
c. Bradycardia
d. Clubbing