A nurse in an urgent care clinic is caring for an infant who presents with vomiting, diarrhea, and decreased oral intake. Which of the following manifestations should the nurse expect?

Hypertension

Decreased temperature

Oliguria

Bulging anterior fontanel

Answer and Explanation

The Correct Answer is C

Rationale:

A. Hypertension: Dehydration in infants typically causes hypotension, not hypertension, due to reduced circulating volume and poor perfusion as fluid loss progresses.

B. Decreased temperature: While temperature may fluctuate in dehydration, fever is more common due to infection-related fluid loss. A decreased temperature is not a consistent sign.

C. Oliguria: Decreased urine output is a key indicator of dehydration in infants. The kidneys conserve water during hypovolemia, resulting in oliguria (less than 1 mL/kg/hr).

D. Bulging anterior fontanel: A bulging fontanel usually indicates increased intracranial pressure, not dehydration. Dehydration typically causes a sunken fontanel in infants.

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Correct Answer is A

Explanation

Rationale:

A. Eat a light snack before bedtime: A light snack can prevent hunger from interfering with sleep and promote relaxation. Complex carbohydrates or small amounts of protein may help induce sleep without causing gastrointestinal discomfort.

B. Perform exercises prior to bedtime: Vigorous physical activity before bed can stimulate the body and make it harder to fall asleep. Exercise is beneficial when done earlier in the day, ideally several hours before bedtime.

C. Stay in bed at least 1 hr if unable to fall asleep: Staying in bed while unable to sleep can create negative associations with the bed and worsen insomnia. It's more effective to get up, engage in a quiet activity, and return to bed once sleepy.

D. Take a 1-hr nap during the day: Long daytime naps can reduce sleep pressure at night and interfere with falling or staying asleep. If needed, naps should be limited to 20–30 minutes and taken early in the day.

A. Nurses notes are used to create the critical pathway B. Critical pathways should reduce health care costs C. Critical pathways have an unlimited timeframe for completion. D. Nurses should discontinue the critical pathway if variances occur

Correct Answer is B

Explanation

Rationale:

A. Nurses notes are used to create the critical pathway: Critical pathways are developed from evidence-based clinical guidelines and best practices, not directly from nurses’ notes. While documentation may help track progress, it is not the foundation for pathway creation.

B. Critical pathways should reduce health care costs: Critical pathways standardize care for specific diagnoses, promoting timely interventions and reducing unnecessary treatments or delays. This efficiency helps lower healthcare costs while improving patient outcomes.

C. Critical pathways have an unlimited timeframe for completion: Each critical pathway includes a defined timeline with expected outcomes for each phase of care. This structure ensures care is efficient and progress is monitored closely to prevent delays or complications.

D. Nurses should discontinue the critical pathway if variances occur: Variances are deviations from the expected outcomes and are used to evaluate and adjust care. They do not justify discontinuing the entire pathway but rather indicate a need for reassessment or individualized modifications.

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A nurse in an urgent care clinic is caring for an infant who presents with vomiting, diarrhea, and decreased oral intake. Which of the following manifestations should the nurse expect?

Nursing Test Bank

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