Tiffany is diagnosed with increased intracranial pressure (ICP); which of the following if stated by her parents would indicate a need for Nurse Charlie to reexplain the purpose for elevating the head of the bed at a 10 to 20-degree angle?

Correct Answer: B

Rationale: Elevating the head of the bed at a 10 to 20-degree angle helps to increase intrathoracic pressure. This increase in pressure can aid in promoting cerebrospinal fluid drainage and reducing intracranial pressure. It is important to maintain the correct angle to achieve the desired effect and avoid potential complications. If Tiffany's parents mention this as the reason for elevating the bed, Nurse Charlie should reexplain the purpose to ensure they understand the intended outcome.

Correct Answer: B

Rationale: When assessing a patient like Will for possible intussusception, the least likely to provide valuable information would be the family history. While family history can help identify potential genetic predispositions or conditions that may contribute to a patient's current health concerns, in this case, the focus is on Will's immediate symptoms and diagnostic indicators related to possible intussusception. Abdominal palpation, pain pattern assessment, and stool inspection are more directly relevant to evaluating Will's current condition and determining the likelihood of intussusception. Family history, while important in a broader health context, would be least likely to provide immediate insights into Will's specific situation with intussusception.

Correct Answer: C

Rationale: Ribavirin (Virazole) is an antiviral medication used to treat severe cases of respiratory syncytial virus (RSV) infection in infants, young children, and immunocompromised individuals. RSV is a common virus that causes respiratory infections in people of all ages, but it can be particularly severe in young children and individuals with weakened immune systems. Ribavirin works by preventing the virus from replicating and spreading further in the body, helping to reduce the severity and duration of RSV infection. It is not used to treat cystic fibrosis, otitis media, or bronchitis.

Correct Answer: D

Rationale: In this situation, the client is experiencing dyspnea, audible wheezing, and decreased oxygen saturation, indicating the presence of respiratory distress, likely due to bronchoconstriction. These are classic symptoms of an acute asthma exacerbation or an obstructive respiratory condition. Beta2 agonists, such as albuterol, are bronchodilators that work by relaxing the muscles in the airways, relieving bronchoconstriction and improving airflow. Administering a beta2 agonist promptly is crucial to provide relief and improve the client's respiratory status. Antibiotics, antivirals, and beta-blockers are not appropriate treatments for acute bronchoconstriction or asthma exacerbation.

Correct Answer: C

Rationale: The nurse would first assess for an irregular heart rate and rhythm. In a 4-month old infant with a congenital heart defect experiencing marked dyspnea at rest, the sudden onset of cyanosis (blue coloration) and increased respiratory rate can indicate worsening heart failure and potential arrhythmias. Assessing for any abnormal heart rhythms is a priority to determine if immediate intervention is required to stabilize the infant's condition and prevent further deterioration.