A nurse is caring for an infant who is being treated for dehydration. Which of the following findings indicates the treatment is effective?

Flat anterior fontanel

Oliguria

Oral intake of 4 oz every 3 hr

Capillary refill 4 seconds

Answer and Explanation

The Correct Answer is C

A. A flat anterior fontanel can indicate dehydration in infants, so this finding does not indicate effective treatment.

B. Oliguria, or decreased urine output, is a sign of dehydration and would not indicate effective treatment.

C. Oral intake of 4 oz every 3 hours indicates that the infant is able to drink fluids and is likely rehydrated, indicating effective treatment.

D. A capillary refill of 4 seconds is prolonged and can indicate poor perfusion, which is not indicative of effective treatment for dehydration.

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Free Nursing Study Resources

Correct Answer is A

Explanation

- A) Hyperreflexia is a common symptom of opioid withdrawal, as the nervous system reacts to the absence of the drug. Patients may experience increased reflex actions and muscle spasms due to the sudden change in opioid levels.
- B) Meiosis, or pupil constriction, is not typically a withdrawal symptom; it is more commonly associated with opioid use. During withdrawal, pupils are likely to dilate rather than constrict.
- C) Euphoria is a feeling of intense happiness or excitement, which is often experienced after taking opioids. During withdrawal, individuals are more likely to experience dysphoria, which is a state of unease or dissatisfaction.
- D) Hypothermia is not a recognized symptom of opioid withdrawal. Instead, individuals may experience fever or chills as the body adjusts to the lack of opioids.

A. Dependent edema B. Pericardial friction rub C. Paradoxical pulse D. Substernal chest pain

Correct Answer is C

Explanation

A. Dependent edema can occur with pericarditis but does not indicate an immediate life-threatening complication.
B. A pericardial friction rub is a common finding in pericarditis and helps confirm the diagnosis but is not the priority.
C. A paradoxical pulse (an exaggerated decrease in systolic blood pressure during inspiration) is a sign of cardiac tamponade, a life-threatening complication of pericarditis, and requires immediate intervention.
D. Substernal chest pain is expected with pericarditis and is usually relieved by sitting up and leaning forward, but it is not the most urgent concern.

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A nurse is caring for an infant who is being treated for dehydration. Which of the following findings indicates the treatment is effective?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

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