TEST BANK - Pediatric Nursing: A Case-
Based Approach 2nd Edition by Gannon
Tagher, Lisa Knapp
CHAPTER 1-34| EXPERT VERIFIED
ANSWERS WITH DETAILED
RATIONALES
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, Chapter 1: Bronchiolitis
1. 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. <ACCURATE ANSWER> 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.
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 <ACCURATE ANSWER> 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.
3. A child has a chronic cough and diffuse wheezing during the expiratory phase of respiration. This
suggests what condition?
a. Asthma
b. Pneumonia
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c. Bronchiolitis
d. Foreign body in trachea <ACCURATE ANSWER> A
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Do
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c
,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.
4. 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) 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.
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
Ar
1. The nurse is caring for a child hospitalized for status asthmaticus. Which assessment finding
suggests that the child’s condition is worsening?
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a. Hypoventilation
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c
, b. Thirst
c. Bradycardia
d. Clubbing <ACCURATE ANSWER> A
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 levels. The nurse would be alert for signs
of hypoxia. Thirst would reflect the child’s hydration status. Bradycardia 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 child’s condition is worsening.
2. Which finding is expected when assessing a child hospitalized for asthma?
a. Inspiratory stridor
b. Harsh, barky cough
c. Wheezing
d. Rhinorrhea <ACCURATE ANSWER> 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.
3. 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?
a. Allergic rhinitis
b. Bronchitis
c. Asthma
d. Sinusitis <ACCURATE ANSWER> 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
Ar
cough. The manifestations of asthma may vary, with wheezing being a classic sign. The symptoms
presented in the question do not suggest asthma.
c h
Do
Page | 4
c
Based Approach 2nd Edition by Gannon
Tagher, Lisa Knapp
CHAPTER 1-34| EXPERT VERIFIED
ANSWERS WITH DETAILED
RATIONALES
Ar
c
h
Do
Page | 1
c
, Chapter 1: Bronchiolitis
1. 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. <ACCURATE ANSWER> 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.
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 <ACCURATE ANSWER> 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.
3. A child has a chronic cough and diffuse wheezing during the expiratory phase of respiration. This
suggests what condition?
a. Asthma
b. Pneumonia
Ar
c. Bronchiolitis
d. Foreign body in trachea <ACCURATE ANSWER> A
c h
Do
Page | 2
c
,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.
4. 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) 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.
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
Ar
1. The nurse is caring for a child hospitalized for status asthmaticus. Which assessment finding
suggests that the child’s condition is worsening?
c
a. Hypoventilation
h
Do
Page | 3
c
, b. Thirst
c. Bradycardia
d. Clubbing <ACCURATE ANSWER> A
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 levels. The nurse would be alert for signs
of hypoxia. Thirst would reflect the child’s hydration status. Bradycardia 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 child’s condition is worsening.
2. Which finding is expected when assessing a child hospitalized for asthma?
a. Inspiratory stridor
b. Harsh, barky cough
c. Wheezing
d. Rhinorrhea <ACCURATE ANSWER> 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.
3. 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?
a. Allergic rhinitis
b. Bronchitis
c. Asthma
d. Sinusitis <ACCURATE ANSWER> 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
Ar
cough. The manifestations of asthma may vary, with wheezing being a classic sign. The symptoms
presented in the question do not suggest asthma.
c h
Do
Page | 4
c
