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?

Bulging anterior fontanel

Decreased temperature

Hypertension

Oliguria

Answer and Explanation

The Correct Answer is D

A. Bulging anterior fontanel. A bulging fontanel is associated with increased intracranial pressure, not dehydration. Dehydration is more likely to cause a sunken fontanel.
B. Decreased temperature. Dehydrated infants typically exhibit normal or elevated temperatures, especially if they have an underlying infection or fever. A decreased temperature is not a common sign of dehydration.
C. Hypertension. Dehydration more commonly leads to hypotension or normal blood pressure, depending on severity. Hypertension is not an expected finding in an infant with fluid volume loss.
D. Oliguria. Decreased urine output (oliguria) is a classic and expected sign of dehydration in infants. It indicates the kidneys are conserving fluid due to inadequate intake and fluid loss from vomiting and diarrhea.

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Correct Answer is A

Explanation

A. Critical pathways should reduce health care costs. Critical pathways, also known as clinical pathways or care maps, are evidence-based, multidisciplinary plans that outline expected care and outcomes for specific conditions. They aim to improve care efficiency, reduce complications, and lower healthcare costs by standardizing care.
B. Nurses should discontinue the critical pathway if variances occur. Variances—deviations from the expected pathway—are documented and analyzed, not a reason to discontinue the pathway. They help identify areas for improvement or necessary adjustments in patient care.
C. Critical pathways have an unlimited timeframe for completion. Critical pathways are time-bound, with specific goals and milestones to be met within a set timeframe based on typical recovery patterns for the condition being treated.
D. Nurses' notes are used to create the critical pathway. Critical pathways are developed using evidence-based guidelines, expert consensus, and clinical research, not individual nurses’ progress notes. However, nurses do document progress and variances within the pathway.

A. Rotate staff members caring for the client. B. Speak in a neutral tone when addressing the client. C. Limit the client's opportunities to socialize with others. D. Mix the medication with the client's food items.

Correct Answer is B

Explanation

A. Rotate staff members caring for the client. Clients with paranoid personality disorder often struggle with mistrust and feel suspicious of others. Consistency in staffing is important to build rapport and reduce anxiety, so rotating staff can worsen paranoia.
B. Speak in a neutral tone when addressing the client. This is appropriate because a calm, neutral, and non-threatening tone helps reduce perceived threats or suspicion. It promotes a sense of safety and control, which is important for therapeutic communication with paranoid individuals.
C. Limit the client's opportunities to socialize with others. While clients with paranoid personality disorder may prefer limited interaction, completely restricting socialization can increase isolation and reinforce delusional thinking. Structured, safe interactions are often encouraged.
D. Mix the medication with the client's food items. Administering medication without the client’s knowledge is deceptive and unethical, especially in someone already prone to distrust. Open and honest communication about treatment is crucial for promoting cooperation and trust.

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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?

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Naxlex Comprehensive Predictor Exams

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