A nurse is caring for a 6-month-old infant who has acute vomiting and diarrhea. Which of the following manifestations should the nurse identify as an indication of moderate hypovolemia?

Capillary refill greater than 4 seconds

Bradycardia

Tachypnea

Lethargy

Answer and Explanation

The Correct Answer is C

A. Capillary refill greater than 4 seconds: This indicates severe hypovolemia, not moderate.
B. Bradycardia: Bradycardia is uncommon in hypovolemia and may occur late as a sign of decompensation, especially in infants.
C. Tachypnea. Tachypnea is a compensatory response to hypovolemia as the body attempts to improve oxygenation and circulation.
D. Lethargy: While lethargy is a concerning sign, it is associated with more severe dehydration than moderate hypovolemia.

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Correct Answer is A

Explanation

A. Applying heat to the affected areas: Heat application promotes vasodilation and helps relieve pain in vaso-occlusive crises. This is a priority because managing pain is critical during a crisis. It can also help improve blood flow and alleviate discomfort.
B. Administering prophylactic antibiotics: While prophylactic antibiotics are important in preventing infections in sickle cell anemia, this is not the immediate priority during a vaso-occlusive crisis.
C. Administering the pneumococcal vaccine: While vaccination is important, it is not a priority during a vaso-occlusive crisis.
D. Promoting bed rest: Bed rest is generally recommended to reduce energy expenditure, but it does not directly address the acute pain or vaso-occlusion that needs to be managed immediately.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

Explanation

1. Failure to thrive: The infant has poor weight gain despite being hungry after vomiting. Projectile vomiting, as described, often leads to insufficient caloric intake, putting the infant at risk for failure to thrive.

2. Dehydration: Repeated vomiting results in fluid loss, putting the infant at high risk of dehydration, which is common in conditions like pyloric stenosis, suspected here due to the symptoms and palpable abdominal mass.

3. Intussusception typically presents with intermittent, severe abdominal pain, "currant jelly" stools, and sometimes a sausage-shaped mass, which are not noted in this scenario.

4. Meckel diverticulum can cause painless rectal bleeding or obstruction symptoms but is not associated with projectile vomiting or a palpable mass.

5. Hirschsprung disease presents with failure to pass meconium, abdominal distension, and chronic constipation rather than the projectile vomiting seen here.

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A nurse is caring for a 6-month-old infant who has acute vomiting and diarrhea. Which of the following manifestations should the nurse identify as an indication of moderate hypovolemia?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for an adolescent client who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following interventions is the nurse's priority?

Correct Answer is A

Explanation

A nurse in a pediatrician's office is caring for an infant. Exhibits Drag words from the choices below to fill in each blank in the following sentence. The infant is at risk for developingdropdownanddropdown.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

Explanation

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