Pediatric Nursing, A Case-Based Approach, 2nd Edition By Tagher
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Knapp
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, Pediatric Nursing, A Case-Based Approach, 2nd Edition By Tagher
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Knapp
gy
gy Which intervention is appropriate for the infant hospitalized with bronchiolitis?
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a. Position on the side with neck slightly flexed.
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b. Administer antibiotics as ordered. gy gy gy
c. Restrict oral and parenteral fluids if tachypneic.
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d. Give cool, humidified oxygen. ANS: D
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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-
gy gy gy gy gy gy gy gy gy gy gy gy gy gy gy gy
degree angle and the neck slightly extended to maintain an open airway and decrease pressure
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on the diaphragm.
gy gy gy
The etiology of bronchiolitis is viral. Antibiotics are given only if there is a secondary bacterial
gy gy gy gy gy gy gy gy gy gy gy gy gy gy gy
infection. Tachypnea increases insensible fluid loss. If the infant is tachypneic, fluids are given
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parenterally to prevent dehydration.
gy gy gy gy
2. An infant with bronchiolitis is hospitalized. The causative organism is respiratory syncytial
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virus (RSV). The nurse knows that a child infected with this virus requires what type of
gy gy gy gy gy gy gy gy gy gy gy gy gy gy gy gy
isolation?
gy
a. Reverse isolation gy
b. Airborne isolation gy
c. Contact Precautions gy
d. Standard Precautions ANS: C gy gy gy
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 room.
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Care is taken not to touch their own eyes or mucous membranes with a contaminated gloved
gy gy gy gy gy gy gy gy gy gy gy gy gy gy gy gy
hand. Children are placed in a private room or in a room with other children with RSV
gy gy gy gy gy gy gy gy gy gy gy gy gy gy gy gy gy
infections. Reverse isolation focuses on keeping bacteria away from the infant. With RSV, other
gy gy gy gy gy gy gy gy gy gy gy gy gy gy
children need to be protected from exposure to the virus. The virus is not airborne.
gy gy gy gy gy gy gy gy gy gy gy gy gy gy gy
, Pediatric Nursing, A Case-Based Approach, 2nd Edition By Tagher
gy gy gy gy gy gy gy gy
Knapp
gy
3. A child has a chronic cough and diffuse wheezing during the expiratory phase of
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respiration. This suggests what condition?
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a. Asthma
b. Pneumonia
c. Bronchiolitis
d. Foreign body in trachea ANS: A gy gy gy gy gy
Asthma may have these chronic signs and symptoms. Pneumonia appears with an acute onset,
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gy 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 stridor.
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4. Which nursing diagnosis is most appropriate for an infant with acute bronchiolitis
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due to respiratory syncytial virus (RSV)?
gy gy gy gy gy gy
a. Activity Intolerance gy
b. Decreased Cardiac Output gy gy
c. Pain, Acute gy
d. Tissue Perfusion, Ineffective (peripheral) ANS. A
gy gy gy gy gy
Rationale 1: Activity intolerance is a problem because of the imbalance between oxygen supply
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and demand. Cardiac output is not compromised during an acute phase of bronchiolitis. Pain is
gy gy gy gy gy gy gy gy gy gy gy gy gy gy gy
not usually associated with acute bronchiolitis. Tissue perfusion (peripheral) is not affected by
gy gy gy gy gy gy gy gy gy gy gy gy gy
this respiratorydisease process.
gy gy gy
Rationale 2: Activity intolerance is a problem because of the imbalance between oxygen supply
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and demand. Cardiac output is not compromised during an acute phase of bronchiolitis. Pain is
gy gy gy gy gy gy gy gy gy gy gy gy gy gy gy
not usually associated with acute bronchiolitis. Tissue perfusion (peripheral) is not affected by
gy gy gy gy gy gy gy gy gy gy gy gy gy
this respiratorydisease process.
gy gy gy
Rationale 3: Activity intolerance is a problem because of the imbalance between oxygen supply
gy gy gy gy gy gy gy gy gy gy gy gy gy
and demand. Cardiac output is not compromised during an acute phase of bronchiolitis. Pain is
gy gy gy gy gy gy gy gy gy gy gy gy gy gy gy
not usually associated with acute bronchiolitis. Tissue perfusion (peripheral) is not affected by
gy gy gy gy gy gy gy gy gy gy gy gy gy
this respiratorydisease process.
gy gy gy
, Pediatric Nursing, A Case-Based Approach, 2nd Edition By Tagher
gy gy gy gy gy gy gy gy
Knapp
gy
Rationale 4: Activity intolerance is a problem because of the imbalance between oxygen supply
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and demand. Cardiac output is not compromised during an acute phase of bronchiolitis. Pain is
gy gy gy gy gy gy gy gy gy gy gy gy gy gy gy
not usually associated with acute bronchiolitis. Tissue perfusion (peripheral) is not affected by
gy gy gy gy gy gy gy gy gy gy gy gy gy
this respiratorydisease process.
gy gy gy
Global Rationale: Activity intolerance is a problem because of the imbalance between oxygen
gy gy gy gy gy gy gy gy gy gy gy gy
supply and demand. Cardiac output is not compromised during an acute phase of bronchiolitis.
gy gy gy gy gy gy gy gy gy gy gy gy gy gy
Pain is not usually associated with acute bronchiolitis. Tissue perfusion (peripheral) is not
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affected by this respiratorydisease process.
gy gy gy gy gy
Chapter 2: Asthma gy gy
1. The nurse is caring for a child hospitalized for status asthmaticus. Which assessment
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finding suggests that the childs condition is worsening?
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a. Hypoventilation
b. Thirst
c. Bradycardia
d. Clubbing ANS: A gy gy
The nurse would assess the child for signs of hypoxia, including restlessness, fatigue, irritability,
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and increased heart and respiratory rate. As the child tires from the increased work of
gy gy gy gy gy gy gy gy gy gy gy gy gy gy gy
breathing hypoventilation occurs leading to increased carbon dioxide levels. The nurse would be
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alert for signs of hypoxia. Thirst would reflect the childs hydration status. Bradycardia is not a
gy gy gy gy gy gy gy gy gy gy gy gy gy gy gy gy
sign of hypoxia; tachycardia is. Clubbing develops over a period of months in response to
gy gy gy gy gy gy gy gy gy gy gy gy gy gy gy
hypoxia. The presence of clubbing does not indicate the childs condition is worsening.
gy gy gy gy gy gy gy gy gy gy gy gy gy
gy gy gy gy gy gy gy gy
Knapp
gy
, Pediatric Nursing, A Case-Based Approach, 2nd Edition By Tagher
gy gy gy gy gy gy gy gy
Knapp
gy
gy Which intervention is appropriate for the infant hospitalized with bronchiolitis?
gy gy gy gy gy gy gy gy gy
a. Position on the side with neck slightly flexed.
gy gy gy gy gy gy gy
b. Administer antibiotics as ordered. gy gy gy
c. Restrict oral and parenteral fluids if tachypneic.
gy gy gy gy gy gy
d. Give cool, humidified oxygen. ANS: D
gy gy gy gy gy
Cool, humidified oxygen is given to relieve dyspnea, hypoxemia, and insensible fluid loss from
gy gy gy gy gy gy gy gy gy gy gy gy gy
tachypnea. The infant should be positioned with the head and chest elevated at a 30- to 40-
gy gy gy gy gy gy gy gy gy gy gy gy gy gy gy gy
degree angle and the neck slightly extended to maintain an open airway and decrease pressure
gy gy gy gy gy gy gy gy gy gy gy gy gy gy
on the diaphragm.
gy gy gy
The etiology of bronchiolitis is viral. Antibiotics are given only if there is a secondary bacterial
gy gy gy gy gy gy gy gy gy gy gy gy gy gy gy
infection. Tachypnea increases insensible fluid loss. If the infant is tachypneic, fluids are given
gy gy gy gy gy gy gy gy gy gy gy gy gy gy
parenterally to prevent dehydration.
gy gy gy gy
2. An infant with bronchiolitis is hospitalized. The causative organism is respiratory syncytial
gy gy gy gy gy gy gy gy gy gy gy
virus (RSV). The nurse knows that a child infected with this virus requires what type of
gy gy gy gy gy gy gy gy gy gy gy gy gy gy gy gy
isolation?
gy
a. Reverse isolation gy
b. Airborne isolation gy
c. Contact Precautions gy
d. Standard Precautions ANS: C gy gy gy
RSV is transmitted through droplets. In addition to Standard Precautions and hand washing,
gy gy gy gy gy gy gy gy gy gy gy gy
Contact Precautions are required. Caregivers must use gloves and gowns when entering the room.
gy gy gy gy gy gy gy gy gy gy gy gy gy
Care is taken not to touch their own eyes or mucous membranes with a contaminated gloved
gy gy gy gy gy gy gy gy gy gy gy gy gy gy gy gy
hand. Children are placed in a private room or in a room with other children with RSV
gy gy gy gy gy gy gy gy gy gy gy gy gy gy gy gy gy
infections. Reverse isolation focuses on keeping bacteria away from the infant. With RSV, other
gy gy gy gy gy gy gy gy gy gy gy gy gy gy
children need to be protected from exposure to the virus. The virus is not airborne.
gy gy gy gy gy gy gy gy gy gy gy gy gy gy gy
, Pediatric Nursing, A Case-Based Approach, 2nd Edition By Tagher
gy gy gy gy gy gy gy gy
Knapp
gy
3. A child has a chronic cough and diffuse wheezing during the expiratory phase of
gy gy gy gy gy gy gy gy gy gy gy gy gy
respiration. This suggests what condition?
gy gy gy gy gy
a. Asthma
b. Pneumonia
c. Bronchiolitis
d. Foreign body in trachea ANS: A gy gy gy gy gy
Asthma may have these chronic signs and symptoms. Pneumonia appears with an acute onset,
gy gy gy gy gy gy gy gy gy gy gy gy gy
gy fever, and general malaise. Bronchiolitis is an acute condition caused by respiratory syncytial
gy gy gy gy gy gy gy gy gy gy gy gy
virus. Foreign body in the trachea occurs with acute respiratory distress or failure and maybe stridor.
gy gy gy gy gy gy gy gy gy gy gy gy gy gy gy
4. Which nursing diagnosis is most appropriate for an infant with acute bronchiolitis
gy gy gy gy gy gy gy gy gy gy gy
due to respiratory syncytial virus (RSV)?
gy gy gy gy gy gy
a. Activity Intolerance gy
b. Decreased Cardiac Output gy gy
c. Pain, Acute gy
d. Tissue Perfusion, Ineffective (peripheral) ANS. A
gy gy gy gy gy
Rationale 1: Activity intolerance is a problem because of the imbalance between oxygen supply
gy gy gy gy gy gy gy gy gy gy gy gy gy
and demand. Cardiac output is not compromised during an acute phase of bronchiolitis. Pain is
gy gy gy gy gy gy gy gy gy gy gy gy gy gy gy
not usually associated with acute bronchiolitis. Tissue perfusion (peripheral) is not affected by
gy gy gy gy gy gy gy gy gy gy gy gy gy
this respiratorydisease process.
gy gy gy
Rationale 2: Activity intolerance is a problem because of the imbalance between oxygen supply
gy gy gy gy gy gy gy gy gy gy gy gy gy
and demand. Cardiac output is not compromised during an acute phase of bronchiolitis. Pain is
gy gy gy gy gy gy gy gy gy gy gy gy gy gy gy
not usually associated with acute bronchiolitis. Tissue perfusion (peripheral) is not affected by
gy gy gy gy gy gy gy gy gy gy gy gy gy
this respiratorydisease process.
gy gy gy
Rationale 3: Activity intolerance is a problem because of the imbalance between oxygen supply
gy gy gy gy gy gy gy gy gy gy gy gy gy
and demand. Cardiac output is not compromised during an acute phase of bronchiolitis. Pain is
gy gy gy gy gy gy gy gy gy gy gy gy gy gy gy
not usually associated with acute bronchiolitis. Tissue perfusion (peripheral) is not affected by
gy gy gy gy gy gy gy gy gy gy gy gy gy
this respiratorydisease process.
gy gy gy
, Pediatric Nursing, A Case-Based Approach, 2nd Edition By Tagher
gy gy gy gy gy gy gy gy
Knapp
gy
Rationale 4: Activity intolerance is a problem because of the imbalance between oxygen supply
gy gy gy gy gy gy gy gy gy gy gy gy gy
and demand. Cardiac output is not compromised during an acute phase of bronchiolitis. Pain is
gy gy gy gy gy gy gy gy gy gy gy gy gy gy gy
not usually associated with acute bronchiolitis. Tissue perfusion (peripheral) is not affected by
gy gy gy gy gy gy gy gy gy gy gy gy gy
this respiratorydisease process.
gy gy gy
Global Rationale: Activity intolerance is a problem because of the imbalance between oxygen
gy gy gy gy gy gy gy gy gy gy gy gy
supply and demand. Cardiac output is not compromised during an acute phase of bronchiolitis.
gy gy gy gy gy gy gy gy gy gy gy gy gy gy
Pain is not usually associated with acute bronchiolitis. Tissue perfusion (peripheral) is not
gy gy gy gy gy gy gy gy gy gy gy gy gy
affected by this respiratorydisease process.
gy gy gy gy gy
Chapter 2: Asthma gy gy
1. The nurse is caring for a child hospitalized for status asthmaticus. Which assessment
gy gy gy gy gy gy gy gy gy gy gy gy
finding suggests that the childs condition is worsening?
gy gy gy gy gy gy gy gy
a. Hypoventilation
b. Thirst
c. Bradycardia
d. Clubbing ANS: A gy gy
The nurse would assess the child for signs of hypoxia, including restlessness, fatigue, irritability,
gy gy gy gy gy gy gy gy gy gy gy gy gy
and increased heart and respiratory rate. As the child tires from the increased work of
gy gy gy gy gy gy gy gy gy gy gy gy gy gy gy
breathing hypoventilation occurs leading to increased carbon dioxide levels. The nurse would be
gy gy gy gy gy gy gy gy gy gy gy gy gy
alert for signs of hypoxia. Thirst would reflect the childs hydration status. Bradycardia is not a
gy gy gy gy gy gy gy gy gy gy gy gy gy gy gy gy
sign of hypoxia; tachycardia is. Clubbing develops over a period of months in response to
gy gy gy gy gy gy gy gy gy gy gy gy gy gy gy
hypoxia. The presence of clubbing does not indicate the childs condition is worsening.
gy gy gy gy gy gy gy gy gy gy gy gy gy
