A child in compensated shock will which symptoms?
Somnolence, hypotension, oliguria
Irritability, tachypnea, hypotension
Irritability, capillary refill time > 2 sec, bradycardia
Irritability, tachycardia, poor peripheral perfusion
The Correct Answer is D
A. Somnolence, hypotension, and oliguria are signs of decompensated shock, not compensated.
B. While irritability and tachypnea are early signs, hypotension indicates progression to decompensated shock.
C. Capillary refill time > 2 sec may occur in shock, but bradycardia is a late and ominous sign in pediatrics.
D. Irritability, tachycardia, and poor peripheral perfusion (e.g., delayed capillary refill, cool extremities) are hallmark signs of compensated shock, where the body is still maintaining blood pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
A. Delayed motor development is not a typical feature of cystic fibrosis, though respiratory and nutritional issues may impact physical development.
B. Cystic fibrosis is autosomal recessive, not dominant, meaning both parents must carry the gene for the child to inherit the disease.
C. Pancreatic enzyme insufficiency occurs in cystic fibrosis, leading to poor digestion and malabsorption.
D. Thick, sticky mucus in the lungs and digestive tract is a hallmark of cystic fibrosis, causing respiratory and gastrointestinal issues.
E. Increased risk for lung infections is common due to mucus buildup in the lungs, which provides a breeding ground for bacteria.
Correct Answer is ["A","D","F"]
Explanation
A. Assess the infant’s airway and perform nasal suctioning as needed: Infants are obligate nose breathers. Significant nasal congestion is present and interfering with feeding and breathing. Suctioning can relieve obstruction and improve oxygenation.
B. Encourage oral fluids to prevent dehydration: The infant is unable to stay latched to breast, showing signs of respiratory distress. Oral fluids are not safe at this time due to risk of aspiration. IV fluids may be required instead.
C. Administer antipyretics as prescribed: The infant's temperature is 99.2°F, which is not febrile. Antipyretics are not indicated.
D. Administer albuterol as prescribed: Bilateral wheezing is present, indicating lower airway involvement. Bronchodilators like albuterol are appropriate to relieve bronchospasm if prescribed.
E. Administer IV antibiotic therapy as prescribed: There is no indication of a bacterial infection at this point. This presentation is more consistent with bronchiolitis, which is typically viral (commonly RSV), and antibiotics are not routinely used unless there is a confirmed bacterial co-infection.
F. Administer oxygen via HHFNC (Heated High-Flow Nasal Cannula): The infant’s O₂ saturation is 92% on room air, which is below the normal threshold (>94% in infants). HHFNC can provide both oxygen and positive airway pressure to ease breathing effort.
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