A 3-week-old infant is admited to the pediatric unit with vomiting and dehydration. The mother describes the infant as having projectile vomiting after eating. She also tells the practical nurse (PN) that the baby is always hungry. Which finding warrants immediate intervention by the PN?

Hyperactive gastric sounds.

Irregular palpable pulse.

Crying without tears.

Underweight for age.

Answer and Explanation

The Correct Answer is B

This finding may indicate a potential cardiac issue that needs immediate medical atention. Projectile vomiting and excessive hunger in a young infant may be signs of pyloric stenosis, a condition in which the muscle between the stomach and small intestine thickens, making it difficult for food to pass through.

Hyperactive gastric sounds may be present with vomiting, but it is not an immediate concern.

Crying without tears may be a sign of dehydration, but it is not an immediate concern.

Underweight for age is a concern but it is not a finding that requires immediate intervention.

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Correct Answer is A

Explanation

Explanation: Acute otitis media is a common childhood illness that refers to an infection of the middle ear. It occurs when the Eustachian tube, which connects the middle ear to the back of the throat, becomes blocked and ﬂuid accumulates in the middle ear. This ﬂuid provides a breeding ground for bacteria, leading to infection and inﬂammation. Symptoms of acute otitis media can include ear pain, fever, irritability, and difficulty hearing. It is important for the PN to provide accurate information to the mother and to explain the treatment plan, which may include antibiotics and pain relief measures, as prescribed by the healthcare provider.

A. Delay administration of nighttime medications until after visitors have left. B. Administer a prescribed PRN benzodiazepine at the onset of a confused state. C. Make certain that the client's assigned room is close to the nurses' station. D. Ask family members about how they dealt with the client in the evening.

Correct Answer is C

Explanation

Restlessness, confusion, and agitation are common symptoms of dementia, particularly in the evening, a phenomenon known as sundowning. Therefore, the PN should implement interventions that can help to prevent or minimize these symptoms. Assigning the client to a room close to the nurses' station can help to provide constant observation and reassurance and can help to prevent the client from wandering or becoming disoriented.
A. Delaying administration of nighttime medications until after visitors have left may be appropriate, but it is not the first intervention to be implemented in this scenario.
B. Administering a prescribed PRN benzodiazepine at the onset of a confused state may be appropriate in some cases, but it should not be the first intervention to be implemented in this scenario.
D. Asking family members about how they dealt with the client in the evening may be helpful, but it is not the first intervention to be implemented in this scenario.

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A 3-week-old infant is admited to the pediatric unit with vomiting and dehydration. The mother describes the infant as having projectile vomiting after eating. She also tells the practical nurse (PN) that the baby is always hungry. Which finding warrants immediate intervention by the PN?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The mother of a 3-year-old asks the practical nurse (PN) to clarify the healthcare provider's diagnosis of acute otitis media. Which is the most accurate explanation?

Correct Answer is A

Explanation

An older client is admitted to the psychiatric unit for assessment of a recent onset of dementia. The practical nurse (PN) notes that in the evening this client often becomes restless, confused, and agitated. Which intervention should the PN implement?

Correct Answer is C

Explanation

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