NURS 3330 Michael Houston Room 303 Med-Surg (ALL EVALUATIONS)
Michael Houston Room 303
Michael Houston, 4-month old admitted with runny nose, decreased
... [Show More] appetite, dehydration, and cough. Respiratory Syncytial Virus (RSV)/Bronchiolitis is suspected. He was born at 36 weeks and spent time in the NICU for respiratory issues and patent ductus venosis that resolved with oxygen treatment and time. A rRT-PCR on nasal secretions is pending, as is a chest xray. Currently Michael is in a croup tent in his car seat. Vital signs are: Temp. 99.3 F, RR 54, HR170 with audible wheezes I don’t’believe we do croup tents anymore. I had to actually look this up. Some hospitals still use croup tents, it just depends on their resources
You responded correctly to 5 out of 6 evaluations: Category
Your response LOC Safety
Educational Health
Pain level Psychological Needs Normal acuity There is no mention of change in LOC
Increased acuity RSV/Bronchiolitis can be quite severe and dangerous in high risk infant Increased acuity Michael is 10 months old hospitalized with possible RSV, parents will n Increased acuity Diagnosis of possible RSV/Bronchiolitis Normal acuity
There is no mention of pain in the report Increased acuity Michael is 10 months old, not able to communicate psychological need
You correctly diagnosed 9 out of 10 options: Physiological
Explanatio
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This study resource wasYour Description Response
Decreased cardiac output False Fatigue
True Fluid volume overload False Impaired gas exchange True Impaired parenting
Ineffective airway clearance
Ineffective breathing pattern
Risk for aspiration Risk for constipation Risk for dehydration
False True True True
False True
Explan
The heart rate will be elevated which will increase Increased respiratory effort leads to greater expe
Children with RSV/Bronchiolitis are often dehydra
Bronchioles are inflamed and constricted; airways gas exchange
There is no mention of impaired parenting in the r health care
Bronchiole constriction, inability to clear airways Increased work of breathing and use of accessory
There are no risk factors for aspiration noted in th There is no risk for constipation noted in the repo Increased work of breathing, child cannot take in
Scenario 1 You correctly ordered 3 out of 5 actions:
Your orde r
2
Correc t order
1 Step
Put on clean isolation gown, ensuring complete coverage front and back
1 2
Don clean mask, ensuring mouth and nose are covered
3 3
Don clean gloves, ensuring gloves cover gown wristlets
4 5 4 5
Enter room, introduce self, and obtain vital signs
Explanation
Complete initial head to toe assessment
Mask is applied after gown but before gloves, ensure mouth and nose are covered appropriately to reduce exposure to pathogen
Gloves are applied and should cover wristlets of gown to reduce contact exposure to skin
Introduction of self to patient and family establishes therapeutic relationship
Complete initial Once vital signs are
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