A nurse is assessing a 3-month-old infant who has diarrhea. Which of the following findings should the nurse expect?
Decreased heart rate
Bulging fontanel
Polyuria
Increased hematocrit
The Correct Answer is D
A. Decreased heart rate: Dehydration typically causes an increased heart rate (tachycardia) rather than a decreased heart rate.
B. Bulging fontanelle: A bulging fontanel can indicate increased intracranial pressure or overhydration. Dehydration, which is more common with diarrhea, would more likely cause a sunken fontanel.
C. Polyuria: Polyuria (increased urine output) is not expected with dehydration. Dehydration often results in oliguria (decreased urine output).
D. Increased haematocrit: Correct. Dehydration can cause hemoconcentration, which leads to an increased haematocrit as the blood becomes more concentrated.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "I will encourage my child to participate in physical activities." Physical activity helps maintain joint function and muscle strength. It is beneficial for managing juvenile idiopathic arthritis.
B. "I will apply cold packs to my child's swollen, painful joints." Warm packs are typically more beneficial for juvenile idiopathic arthritis to relieve pain and stiffness. Cold packs are less commonly recommended.
C. "I will administer NSAIDs 1 hour before meals." NSAIDs should be given with food or milk to minimize gastrointestinal irritation, not before meals.
D. "I will dress my child and clean their room for them." Encouraging independence is important. While assistance may be necessary during flares, fostering independence is crucial for self-esteem and physical function.
Correct Answer is D
Explanation
A. Respiratory rate 70/min: A respiratory rate of 70/min is high for an infant and may indicate ongoing respiratory distress or other issues. Normal respiratory rates for infants are generally 30-60 breaths per minute. This does not indicate improvement.
B. Capillary refill is greater than 3 seconds. Capillary refill time greater than 3 seconds indicates poor perfusion, which can be a sign of continued dehydration or shock. This does not indicate improvement.
C. Dry mucous membranes: Dry mucous membranes are a sign of dehydration. For an infant's condition to be improving, mucous membranes should be moist.
D. Fontanelle is level and soft. A level and soft fontanelle indicates that the infant is likely well-hydrated. Sunken fontanelles are a sign of dehydration, so this finding suggests improvement in the infant’s hydration status.
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