A nurse is assessing a child who has an acute kidney injury. Which of the following clinical manifestations should the nurse expect?
Decreased respiratory rate
Polyuria
Hyperactivity
Edema
The Correct Answer is D
A. Decreased respiratory rate:
Respiratory rate may increase due to fluid overload and acidosis, but decreased rate is not typical.
B. Polyuria:
In the initial phase of AKI, oliguria (low urine output) is common, not polyuria.
C. Hyperactivity:
Hyperactivity is unrelated to AKI; lethargy and confusion are more likely.
D. Edema:
Edema occurs due to fluid retention from decreased urine output in acute kidney injury (AKI).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Droplet
Pertussis (whooping cough) is transmitted via respiratory droplets. Droplet precautions (mask, private room if possible) are essential to prevent spread.
B. Contact
Contact precautions are for pathogens spread via direct touch (e.g., C. difficile, RSV), not primarily droplet-borne infections like pertussis.
C. Airborne
Airborne precautions are for diseases like tuberculosis, measles, and varicella. Pertussis does not require negative pressure rooms.
D. Protective environment
This is for immunocompromised clients (e.g., stem cell transplant patients) to protect them from pathogens-not to prevent them from infecting others.
Correct Answer is D
Explanation
A. Depressed scalp veins
Scalp veins would likely be distended or prominent due to increased intracranial pressure, not depressed.
B. Sunken anterior fontanels
The fontanelle would be bulging, not sunken, in hydrocephalus due to increased intracranial pressure.
C. Bulging eyes
Hydrocephalus does not typically cause bulging eyes. "Sunsetting eyes" (downward gaze with visible sclera above the iris) may be seen instead.
D. Separated cranial sutures
Increased intracranial pressure from excess cerebrospinal fluid (CSF) causes the sutures to separate due to skull expansion in infants.
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