Difficulty: Medium
Average Score: 77%
Simulated
Passage / Scenario
Infant was full-term at birth. Birth weight was 3.5 kg (7.7 lb). Infant is not gaining weight as expected. One week ago at outpatient visit, weight was 3.6 kg (7.9 lb). Parent reports for past 2 days infant is breathing faster during feedings and does not finish feedings. Parent also reports decreased appetite and puffiness around the infant's eyes. Parent states that the last wet diaper was about 10 hr ago. Infant admitted for diagnostic evaluation, failure to thrive, and nutritional/fluid support. Vital Signs Admission: Temperature 37.7° C (99.9° F), Heart rate 174/min while sleeping, Respiratory rate 72/min while sleeping. Assessment: Respirations: Tachypneic with moderate retractions and nasal flaring. Upon auscultation, crackles heard in all lung fields. No nasal drainage noted. Dry cough noted periodically. Skin: Pallor, scalp is diaphoretic, lower extremities are cool to touch. Cardiac: Tachycardic, regular rhythm, no murmur is heard. Peripheral pulses are full and bounding in the upper extremities and weak bilateral pedal pulses are noted. Fluids: Mucous membranes are slightly dry and pink. Skin turgor is slightly decreased. Capillary refill is 3 seconds. Noted periorbital edema and nonpitting edema of feet. Anterior fontanel is soft and slightly depressed. Diaper remains dry. Abdomen: Soft, full, round, bowel sounds are present and active. Blood pressure in right upper extremity 60/39 mm Hg, Oxygen saturation 90%. Laboratory Results: Chest x-ray: mild left ventricular hypertrophy is noted. Increased pulmonary vascular markings are noted in all lobes.Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Correct answer
C (Condition), A,B (Actions), B,C (Parameters)
Rationale
Action to Take: Provide chest physiotherapy and postural drainage, Elevate the head of the bed to a 45┬░ angle; Potential Condition: Respiratory syncytial virus bronchiolitis; Parameter to Monitor: Intake and output, Respiratory status.
Rationale: For a client most likely experiencing respiratory syncytial virus bronchiolitis, the nurse should provide chest physiotherapy and postural drainage to help clear secretions and elevate the head of the bed to improve breathing. Monitoring intake and output helps assess hydration status, and monitoring respiratory status is crucial in evaluating the client's response to treatment and progression of the condition.
Incorrect choices: A includes conditions unrelated to the client's symptoms. B involves actions for different conditions and medications. C includes parameters not directly related to the potential condition.
Rationale: For a client most likely experiencing respiratory syncytial virus bronchiolitis, the nurse should provide chest physiotherapy and postural drainage to help clear secretions and elevate the head of the bed to improve breathing. Monitoring intake and output helps assess hydration status, and monitoring respiratory status is crucial in evaluating the client's response to treatment and progression of the condition.
Incorrect choices: A includes conditions unrelated to the client's symptoms. B involves actions for different conditions and medications. C includes parameters not directly related to the potential condition.