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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
One of the most important interventions in caring for clients with major depressive disorder is building a therapeutic relationship. Scheduling regular periods of time for interaction with the client demonstrates support and provides an opportunity for the client to express their feelings and concerns. Journaling and self-reflection can be helpful interventions for some clients, but they do not necessarily demonstrate support.
Assisting the client to identify symptoms of depression is important for assessment and care planning, but it is not a way to demonstrate support.
Incorporating animated communication techniques may be appropriate for certain clients, but it is not a universal intervention for supporting clients with major depressive disorder.
Correct Answer is C
Explanation
Albuminuria, or the presence of albumin in the urine, is an early sign of relapse in a toddler with minimal change nephrotic syndrome (MCNS) who has been treated with corticosteroids. MCNS is a kidney disorder that can cause the body to excrete too much protein in the urine, leading to albuminuria. The practical nurse should recognize this finding as an early sign of relapse and take appropriate action to manage the child's condition.
The other answers are incorrect because they are not directly related to the early signs of relapse in a toddler with minimal change nephrotic syndrome (MCNS) who has been treated with corticosteroids.
- Increased thirst is not a known early sign of relapse in MCNS.
- Tachypnea, or rapid breathing, is not a known early sign of relapse in MCNS.
- A rounded face can be a side effect of corticosteroid treatment, but it is not an early sign of relapse in MCNS.
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