TEST BANK n
Pediatric Nursing, A Case-
n n n
n Based Approach, 1st Edition ByT
n n n n n
agher Knapp n
, PediatricnNursing,nAnCase-BasednApproach,n1stnEditionnBynTaghernKnapp
Chaptern1:nBronchiolitis
1. Whichninterventionnisnappropriatenforntheninfantnhospitalizednwithnbronchiolitis?
a. Positionnonnthensidenwithnnecknslightlynflexed.
b. Administernantibioticsnasnordered.
c. Restrictnoralnandnparenteralnfluidsnifntachypneic.
d. Givencool,nhumidifiednoxygen.nANS:nD
Cool,nhumidifiednoxygennisngivenntonrelievendyspnea,nhypoxemia,nandninsensiblenfluidnlossnfrom
tachypnea.nTheninfantnshouldnbenpositionednwithnthenheadnandnchestnelevatednatnan30-nton40-
degreenanglenandnthennecknslightlynextendedntonmaintainnannopennairwaynandndecreasenpressurenonnthe
ndiaphragm.nThenetiologynofnbronchiolitisnisnviral.nAntibioticsnarengivennonlynifntherenisnansecondarynbact
erialninfection.nTachypneanincreasesninsensiblenfluidnloss.nIfntheninfantnisntachypneic,nfluidsnarengivennpar
enterallyntonpreventndehydration.
2. Anninfantnwithnbronchiolitisnisnhospitalized.nThencausativenorganismnisnrespiratorynsyncytialnviru
sn(RSV).nThennursenknowsnthatnanchildninfectednwithnthisnvirusnrequiresnwhatntypenofnisolation?
a. Reversenisolation
b. Airbornenisolation
c. ContactnPrecautions
d. StandardnPrecautionsnANS:nC
RSVnisntransmittednthroughndroplets.nInnadditionntonStandardnPrecautionsnandnhandnwashing,
ContactnPrecautionsnarenrequired.nCaregiversnmustnusenglovesnandngownsnwhennenteringnthenroom.nCar
enisntakennnotntontouchntheirnownneyesnornmucousnmembranesnwithnancontaminatednglovednhand.nChildr
ennarenplacedninnanprivatenroomnorninnanroomnwithnothernchildrennwithnRSVninfections.nReversenisolation
, PediatricnNursing,nAnCase-BasednApproach,n1stnEditionnBynTaghernKnapp
focusesnonnkeepingnbacterianawaynfromntheninfant.nWithnRSV,nothernchildrennneedntonbenprotectednfro
mnexposurentonthenvirus.nThenvirusnisnnotnairborne.
3. Anchildnhasnanchronicncoughnandndiffusenwheezingnduringnthenexpiratorynphasenofnrespiration.nThi
snsuggestsnwhatncondition?
a. Asthma
b. Pneumonia
c. Bronchiolitis
d. ForeignnbodyninntracheanANS:nA
Asthmanmaynhaventhesenchronicnsignsnandnsymptoms.nPneumonianappearsnwithnannacutenonset
,nfever,nandngeneralnmalaise.nBronchiolitisnisnannacutenconditionncausednbynrespiratorynsyncytial
virus.nForeignnbodyninnthentracheanoccursnwithnacutenrespiratoryndistressnornfailurenandnmaybenstridor.
4. Whichnnursingndiagnosisnisnmostnappropriatenfornanninfantnwithnacutenbronchiolitisnduent
onrespiratorynsyncytialnvirusn(RSV)?
a. ActivitynIntolerance
b. DecreasednCardiacnOutput
c. Pain,nAcute
d. TissuenPerfusion,nIneffectiven(peripheral)nANS.nA
Rationalen1:nActivitynintolerancenisnanproblemnbecausenofnthenimbalancenbetweennoxygennsupplynandnd
emand.nCardiacnoutputnisnnotncompromisednduringnannacutenphasenofnbronchiolitis.nPainnisnnotnusuallyn
associatednwithnacutenbronchiolitis.nTissuenperfusionn(peripheral)nisnnotnaffectednbynthisnrespiratory-
ndiseasenprocess.
Rationalen2:nActivitynintolerancenisnanproblemnbecausenofnthenimbalancenbetweennoxygennsupplynandnd
emand.nCardiacnoutputnisnnotncompromisednduringnannacutenphasenofnbronchiolitis.nPainnisnnotnusuallyn
associatednwithnacutenbronchiolitis.nTissuenperfusionn(peripheral)nisnnotnaffectednbynthisnrespiratory-
ndiseasenprocess.
, PediatricnNursing,nAnCase-BasednApproach,n1stnEditionnBynTaghernKnapp
Rationalen3:nActivitynintolerancenisnanproblemnbecausenofnthenimbalancenbetweennoxygennsupplynandnd
emand.nCardiacnoutputnisnnotncompromisednduringnannacutenphasenofnbronchiolitis.nPainnisnnotnusuallyn
associatednwithnacutenbronchiolitis.nTissuenperfusionn(peripheral)nisnnotnaffectednbynthisnrespiratory-
ndiseasenprocess.
Rationalen4:nActivitynintolerancenisnanproblemnbecausenofnthenimbalancenbetweennoxygennsupplynandnd
emand.nCardiacnoutputnisnnotncompromisednduringnannacutenphasenofnbronchiolitis.nPainnisnnotnusuallyn
associatednwithnacutenbronchiolitis.nTissuenperfusionn(peripheral)nisnnotnaffectednbynthisnrespiratory-
ndiseasenprocess.
GlobalnRationale:nActivitynintolerancenisnanproblemnbecausenofnthenimbalancenbetweennoxygennsupplynan
dndemand.nCardiacnoutputnisnnotncompromisednduringnannacutenphasenofnbronchiolitis.nPainnisnnotnusuallyn
associatednwithnacutenbronchiolitis.nTissuenperfusionn(peripheral)nisnnotnaffectednbynthisnrespiratory-
ndiseasenprocess.
Chaptern2:nAsthma
1. Thennursenisncaringnfornanchildnhospitalizednfornstatusnasthmaticus.nWhichnassessmentnfindin
gnsuggestsnthatnthenchildsnconditionnisnworsening?
a. Hypoventilation
b. Thirst
c. Bradycardia
d. ClubbingnANS:nA
Thennursenwouldnassessnthenchildnfornsignsnofnhypoxia,nincludingnrestlessness,nfatigue,nirritability,nandnincre
asednheartnandnrespiratorynrate.nAsnthenchildntiresnfromnthenincreasednworknofnbreathingnhypoventilationno
ccursnleadingntonincreasedncarbonndioxidenlevels.nThennursenwouldnbenalertnfornsignsnof