A 10-year-old child was admitted with full-thickness burns affecting more than 15% of the child’s body surface. What manifestations of hypovolemic shock would you observe for over the next 48 hrs? Select all choices that apply:
Rapid pulse.
Decreased B/P.
Pallor.
Flushed Face.
Correct Answer : A,B,C
Choice A rationale
Rapid pulse is a common manifestation of hypovolemic shock. When the body experiences a significant loss of fluid, such as in severe burns, the heart rate increases in an attempt to maintain adequate blood flow and oxygen delivery to the body’s tissues.
Choice B rationale
Decreased blood pressure is another typical sign of hypovolemic shock. As the body loses fluid, the volume of blood circulating through the body decreases. This drop in blood volume leads to a decrease in blood pressure.
Choice C rationale
Pallor, or paleness of the skin, can occur in hypovolemic shock. This happens because the body prioritizes sending blood to vital organs like the heart and brain, which can result in less blood flow to the skin, causing it to appear pale.
Choice D rationale
A flushed face is not typically associated with hypovolemic shock. In fact, the skin may actually appear pale or cool due to reduced blood flow.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Gastroesophageal Reflux Disease (GERD) in infants is a condition where the stomach contents flow back into the esophagus causing discomfort. However, the symptoms described, such as projectile vomiting and constant hunger, are more consistent with Pyloric Stenosis.
Choice B rationale
Pyloric Stenosis is a condition in infants where the opening from the stomach to the small intestine narrows, preventing food from entering the small intestine. The symptoms described by the parents, such as projectile vomiting after every feeding and constant hunger, align with this condition. The infant’s lack of weight gain could be due to the fact that food is not being properly digested and absorbed. The nurse should refer the infant for a surgical consultation as the treatment for Pyloric Stenosis is usually surgical. The nurse should monitor the infant’s weight and frequency of vomiting to assess the infant’s progress.
Choice C rationale
Lactose Intolerance in infants is a condition where the infant has difficulty digesting lactose, a sugar found in milk and dairy products. Symptoms can include gas, bloating, and diarrhea.
However, the symptoms described by the parents do not align with this condition.
Choice D rationale
Milk Protein Allergy in infants is a condition where the infant’s immune system reacts negatively to the proteins in cow’s milk. Symptoms can include hives, itching, wheezing, difficulty breathing, constipation, and bloody diarrhea. However, the symptoms described by the parents do not align with this condition.
Correct Answer is B
Explanation
Choice A rationale
Jaundice, a yellowing of the skin and eyes, is not typically a symptom of Wilms’ tumor. It is more commonly associated with conditions that cause liver dysfunction.
Choice B rationale
An abdominal mass is one of the most common symptoms of Wilms’ tumor. Parents or healthcare providers may feel a lump or swelling in the child’s abdomen.
Choice C rationale
Swollen joints are not a typical symptom of Wilms’ tumor. They are more commonly associated with conditions that affect the joints, such as juvenile arthritis.
Choice D rationale
Diarrhea is not a typical symptom of Wilms’ tumor. It is more commonly a symptom of gastrointestinal illnesses.
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