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NursingACase-Based
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Approach 1st Edition ix ix
Tagher Knapp
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, Pediatric Nursing – A Case-Based Approach 1st Edition Tagher Knapp Test Bank
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Chapter 1: v Bronchiolitis
1. Which intervention is appropriate for the infant hospitalized with bronchiolitis?
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a. Position on the side with neck slightly flexed. v v v v v v v
b. Administer antibiotics as ordered. v v v
c. Restrict oral and parenteral fluids if tachypneic.
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d. Givecool,humidifiedoxygen. v
vANS: D v
Cool, humidified oxygen is given to relieve dyspnea, hypoxemia, and insensible fluid loss from
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tachypnea. The infant should be positioned with the head and chest elevated at a 30- to 40-degree
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vangle and the neck slightly extended to maintain an open airway and decrease pressure on the
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vdiaphragm. The etiology of bronchiolitis is viral. Antibiotics are given only if there is a
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vsecondary bacterial infection. Tachypnea increases insensible fluid loss. If the infant is
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vtachypneic, fluids are given parenterally to prevent dehydration.
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2. An infant with bronchiolitis is hospitalized. The causative organism is respiratory
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vsyncytial virus (RSV). The nurse knows that a child infected with this virus requires what
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vtype of isolation?
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a. Reverse isolation v
b. Airborne isolation v
c. Contact Precautions v
d. StandardPrecautions
vANS: C v
RSV is transmitted through droplets. In addition to Standard Precautions and hand washing,
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Contact Precautions are required. Caregivers must use gloves and gowns when entering the
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vroom. Care is taken not to touch their own eyes or mucous membranes with a contaminated
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vgloved hand. Children are placed in a private room or in a room with other children with RSV
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vinfections. Reverse isolation focuses on keeping bacteria away from the infant. With RSV, other
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vchildren need to be protected from exposure to the virus. The virus is not airborne.
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3. A child has a chronic cough and diffuse wheezing during the expiratory phase of
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vrespiration. This suggests what condition? v v v v
a. Asthma
b. Pneumonia
c. Bronchiolitis
d. Foreign bodyintrachea ix v
vANS: A v
Asthma may have these chronic signs and symptoms. Pneumonia appears with an acute onset,
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fever, and general malaise. Bronchiolitis is an acute condition caused by respiratory syncytial
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,virus. Foreign body in the trachea occurs with acute respiratory distress or failure and maybe
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vstridor.
4. Which nursing diagnosis is most appropriate for an infant with acute bronchiolitis due
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vto respiratory syncytial virus (RSV)?
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a. Activity Intolerance v
b. Decreased Cardiac Output v v
c. Pain, Acute v
d. TissuePerfusion,Ineffective(peripheral) v
vANS. A v
Rationale 1: Activity intolerance is a problem because of the imbalance between oxygen supply
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vand demand. Cardiac output is not compromised during an acute phase of bronchiolitis. Pain is
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vnot usually associated with acute bronchiolitis. Tissue perfusion (peripheral) is not affected by
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vthis respiratory-disease process.
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Rationale 2: Activity intolerance is a problem because of the imbalance between oxygen supply
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vand demand. Cardiac output is not compromised during an acute phase of bronchiolitis. Pain is
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vnot usually associated with acute bronchiolitis. Tissue perfusion (peripheral) is not affected by
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vthis respiratory-disease process.
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Rationale 3: Activity intolerance is a problem because of the imbalance between oxygen supply
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vand demand. Cardiac output is not compromised during an acute phase of bronchiolitis. Pain is
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vnot usually associated with acute bronchiolitis. Tissue perfusion (peripheral) is not affected by
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vthis respiratory-disease process.
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Rationale 4: Activity intolerance is a problem because of the imbalance between oxygen supply
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vand demand. Cardiac output is not compromised during an acute phase of bronchiolitis. Pain is
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vnot usually associated with acute bronchiolitis. Tissue perfusion (peripheral) is not affected by
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vthis respiratory-disease process.
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Global Rationale: Activity intolerance is a problem because of the imbalance between oxygen
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vsupply and demand. Cardiac output is not compromised during an acute phase of bronchiolitis.
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vPain is not usually associated with acute bronchiolitis. Tissue perfusion (peripheral) is not
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vaffected by this respiratory-disease process.
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Chapter 2: Asthma v v
1. The nurse is caring for a child hospitalized for status asthmaticus. Which assessment finding
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vsuggests that the childs condition is worsening?
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a. Hypoventilation
b. Thirst
c. Bradycardia
d. Clubbing
ANS: A
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, The nurse would assess the child for signs of hypoxia, including restlessness, fatigue, irritability,
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vand increased heart and respiratory rate. As the child tires from the increased work of breathing
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vhypoventilation occurs leading to increased carbon dioxide levels. The nurse would be alert for
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vsigns of hypoxia. Thirst would reflect the childs hydration status. Bradycardia is not a sign of
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vhypoxia; tachycardia is. Clubbing develops over a period of months in response to hypoxia. The
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vpresence of clubbing does not indicate the childs condition is worsening.
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2. Which finding is expected when assessing a child hospitalized for asthma?
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a. Inspiratory stridor v
b. Harsh, barky cough v v
c. Wheezing
d. Rhinorrhea
vANS: C v
Wheezing is a classic manifestation of asthma. Inspiratory stridor is a clinical manifestation of
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croup. A harsh, barky cough is characteristic of croup. Rhinorrhea is not associated with asthma.
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3. A child has had cold symptoms for more than 2 weeks, a headache, nasal congestion with
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vpurulent nasal drainage, facial tenderness, and a cough that increases during sleep. The nurse
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vrecognizes these symptoms are characteristic of which respiratory condition?
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a. Allergic rhinitis v
b. Bronchitis
c. Asthma
d. Sinusitis
vANS: D v
Sinusitis is characterized by signs and symptoms of a cold that do not improve after 14 days, a
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low-grade fever, nasal congestion and purulent nasal discharge, headache, tenderness, a feeling
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vof fullness over the affected sinuses, halitosis, and a cough that increases when the child is
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vlying down. The classic symptoms of allergic rhinitis are watery rhinorrhea, itchy nose, eyes,
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vears, and palate, and sneezing. Symptoms occur as long as the child is exposed to the allergen.
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vBronchitis is characterized by a gradual onset of rhinitis and a cough that is initially
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vnonproductive but may change to a loose cough. The manifestations of asthma may vary, with
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vwheezing being a classic sign. The symptoms presented in the question do not suggest asthma.
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4. What is a common trigger for asthma attacks in children?
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a. Febrile episodes v
b. Dehydration
c. Exercise
d. Seizures
ANS: C
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