A nurse is collecting data from an infant who has gastroesophageal reflux. Which of the following findings should the nurse expect? (Select the 3 that apply.)
Wheezing
Rigid abdomen
Pallor
Weight loss
Vomiting
Correct Answer : A,D,E
A. Wheezing: Wheezing is a common symptom associated with asthma, which can be exacerbated by gastroesophageal reflux (GER) in infants. GER occurs when stomach contents flow back into the esophagus, leading to irritation and inflammation of the airways. This inflammation can cause wheezing sounds during breathing, especially if the refluxed material reaches the lower respiratory tract.
B. Rigid abdomen: While gastroesophageal reflux (GER) primarily affects the upper gastrointestinal tract, it typically does not cause a rigid abdomen. A rigid abdomen may indicate other underlying gastrointestinal issues such as bowel obstruction, intussusception, or peritonitis. These conditions are not typically associated with GER in infants.
C. Pallor: Pallor, or paleness of the skin, is not a common symptom of gastroesophageal reflux (GER) in infants. GER primarily affects the upper gastrointestinal tract and is characterized by symptoms such as spitting up, regurgitation, and irritability. Pallor may be indicative of other health issues such as anemia or circulatory problems but is not directly related to GER.
D. Weight loss: Weight loss can occur in infants with gastroesophageal reflux (GER) if frequent vomiting leads to inadequate intake of nutrients. However, it is not a direct symptom of GER itself. Infants with GER may experience feeding difficulties, irritability, and discomfort associated with feeding, which can contribute to poor weight gain over time if not managed effectively.
E. Vomiting: Vomiting is a common symptom of gastroesophageal reflux (GER) in infants. It occurs when stomach contents flow back up into the esophagus and sometimes out of the mouth. Infants with GER may spit up or vomit frequently after feeding or during burping, which can lead to discomfort and irritability. Vomiting may also contribute to poor weight gain and nutritional deficiencies if not managed effectively.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Orange-tinged urine
- This manifestation is not typically associated with nephrotic syndrome. Orange-tinged urine may indicate other conditions such as dehydration, liver disease, or the presence of certain medications or foods.
B. Hypertension
- Hypertension is not a common manifestation of nephrotic syndrome. However, it can occur in some cases due to the retention of sodium and water, which can lead to fluid overload and increased blood pressure.
C. Periorbital edema
- This is a classic manifestation of nephrotic syndrome. Periorbital edema, or swelling around the eyes, is often one of the initial signs observed in children with nephrotic syndrome due to the loss of protein in the urine, leading to fluid accumulation in the tissues.
D. Polyuria
- Polyuria, or increased urine output, is not typically associated with nephrotic syndrome. Instead, children with nephrotic syndrome may experience oliguria or normal urine output, depending on the severity of renal involvement and fluid balance.
Correct Answer is B
Explanation
A. Place new linen on the client's bed every other day: While changing linen regularly is important for maintaining cleanliness and preventing infection, waiting every other day may not be sufficient for a client with burns, especially if there is wound drainage or soiling. Linens should be changed more frequently, ideally daily or as needed, to ensure cleanliness and prevent the spread of infection.
B. Change gloves between sites when providing wound care to multiple wounds: This is a correct action. Changing gloves between sites when providing wound care helps prevent the spread of infection from one wound to another. It reduces the risk of cross-contamination and helps maintain a sterile environment during wound care procedures.
C. Change the dressing on infected wounds first: This is incorrect. Dressings on infected wounds should be changed promptly to prevent the spread of infection. However, changing the dressing on infected wounds first may lead to contamination of other wound sites if proper precautions are not taken. It's important to follow proper infection control procedures, including changing gloves between wound sites and using aseptic technique.
D. Monitor vital signs every 4 hr: Monitoring vital signs is important for assessing the client's overall condition, but it is not directly related to preventing infection. Vital signs may indicate signs of infection, such as fever or increased heart rate, but they do not prevent infection on their own. Other measures, such as wound care and infection control practices, are more directly related to preventing infection in clients with burns.
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