A child in compensated shock will show which symptoms?
Somnolence, hypotension, oliguria
Irritability, tachypnea, hypotension
Irritability, capillary refill time > 2 seconds, bradycardia
Irritability, tachycardia, poor peripheral perfusion
The Correct Answer is D
Choice A reason: Somnolence, hypotension, and oliguria are signs of decompensated shock, which occurs when the body's compensatory mechanisms fail to maintain adequate tissue perfusion.
Choice B reason: Irritability, tachypnea, and hypotension are also signs of decompensated shock, as the respiratory rate increases to compensate for the low blood pressure and oxygen delivery.
Choice C reason: Irritability, capillary refill time > 2 seconds, and bradycardia are not typical signs of compensated shock, as the heart rate usually increases to maintain cardiac output and blood pressure.
Choice D reason: Irritability, tachycardia, and poor peripheral perfusion are signs of compensated shock, which occurs when the body tries to maintain adequate tissue perfusion by increasing the heart rate, constricting the peripheral blood vessels, and shunting blood to the vital organs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This statement is incorrect, as maceration is not a clinical manifestation of scabies, but a condition of softening and breaking down of the skin due to prolonged exposure to moisture. Maceration can occur in areas where the skin folds or rubs together, such as the groin, armpits, or under the breasts.
Choice B reason: This statement is incorrect, as edema is not a clinical manifestation of scabies, but a condition of swelling due to excess fluid accumulation in the tissues. Edema can occur in various parts of the body, such as the legs, feet, hands, or face, due to various causes, such as heart failure, kidney disease, or allergic reactions.
Choice C reason: This statement is correct, as itching is the primary clinical manifestation of scabies, a contagious skin infection caused by the mite Sarcoptes scabiei. The mite burrows into the skin and lays eggs, causing an intense inflammatory response and pruritus. The itching is usually worse at night and affects the areas between the fingers, wrists, elbows, armpits, waist, buttocks, and genitals.
Choice D reason: This statement is incorrect, as severe pain is not a clinical manifestation of scabies, but a subjective sensation of physical discomfort or distress. Pain can occur in various parts of the body due to various causes, such as injury, inflammation, infection, or disease. Pain can be acute or chronic, and can be rated on a scale of 0 to 10.
Correct Answer is D
Explanation
Choice A reason: This statement is incorrect, as burping the infant after feeding is not a nursing intervention, but a normal practice to prevent gas and discomfort. The nurse should encourage the mother to burp the infant gently after each feeding, and to avoid overfeeding or underfeeding the infant.
Choice B reason: This statement is incorrect, as giving five milliliters of water is not a nursing intervention, but a harmless amount of fluid for the infant. The nurse should inform the mother that water is not necessary for the infant, as breast milk or formula provides enough hydration and nutrition. However, the nurse should also reassure the mother that a small amount of water will not harm the infant.
Choice C reason: This statement is incorrect, as wrapping the infant during feeding is not a nursing intervention, but a comforting measure for the infant. The nurse should support the mother's bonding with the infant, and suggest ways to make the feeding experience more pleasant and relaxing for both of them. The nurse should also monitor the infant's temperature and avoid overheating.
Choice D reason: This statement is correct, as giving thirty milliliters of water is a nursing intervention that indicates a need for further education and guidance. The nurse should explain to the mother that giving too much water to the infant can cause water intoxication, which can lead to hyponatremia, seizures, or even death. The nurse should also teach the mother the signs and symptoms of water intoxication, such as irritability, lethargy, vomiting, or swelling.
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