A nurse is obtaining vital signs from the 2-month-old infant. The infant's heart rate is 190/min, and his temperature is 40° C (104° F). The father asks the nurse why the infant's heart is beating so fast. Which of the following responses by the nurse is appropriate?
"The fever is causing an increase in your baby's heart rate."
"This is within the expected range for your baby."
"Your baby's heart is beating fast in an attempt to cool down his body."
"As your baby begins to fall asleep, his heart rate will decrease."
The Correct Answer is A
A. "The fever is causing an increase in your baby's heart rate." Fever increases metabolic demand, which commonly leads to tachycardia in infants as the body attempts to regulate temperature and support circulation. This explanation directly addresses the physiological cause and is appropriate.
B. "This is within the expected range for your baby." A heart rate of 190/min in a 2-month-old is elevated, especially in the presence of a fever. While infants have higher baseline heart rates (120-160 b/min), this value is elevated and requires clinical interpretation, not reassurance.
C. "Your baby's heart is beating fast in an attempt to cool down his body.": While increased cardiac output may help distribute heat, the primary cause of tachycardia is metabolic demand from fever—not a direct mechanism to cool the body.
D. "As your baby begins to fall asleep, his heart rate will decrease." Although heart rate may decrease with sleep, this does not address the father's concern about the elevated rate now, and it downplays the need to monitor the infant in the context of high fever
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["5.3"]
Explanation
Convert the child's weight from pounds (lb) to kilograms (kg).
Weight in kg = 28 lb / 2.2 lb/kg
= 12.727 kg
Calculate the total desired dose in milligrams (mg).
Desired dose (mg) = Desired dose (mg/kg/dose) × Weight (kg)
= 10 mg/kg/dose × 12.727 kg
= 127.27 mg
Available concentration of the acetaminophen oral solution
= 120 mg / 5 mL.
Calculate the volume in milliliters (mL) to administer.
Volume (mL) = Desired dose (mg) / (Available concentration (mg) / Available volume (mL))
= 127.27 mg / (120 mg / 5 mL)
= 127.27 mg × (5 mL / 120 mg)
= (127.27 × 5) / 120 mL
= 636.35 / 120 mL
= 5.302 mL
Round the answer to the nearest tenth.
= 5.3 mL.
Correct Answer is C
Explanation
A. Family conflict: Ongoing family conflict can contribute to emotional distress and increase suicide risk, but it is not the most immediate or direct indicator. It often interacts with other factors, such as mental health status, to influence risk.
B. Availability of firearms: Access to firearms significantly raises the lethality of suicide attempts and is an important environmental risk factor. However, without an underlying psychiatric issue or suicidal ideation, availability alone is not the strongest predictor.
C. Active psychiatric disorder: The presence of an active psychiatric disorder, such as depression, bipolar disorder, or anxiety, is the most significant risk factor for suicide. These conditions often impair judgment, increase hopelessness, and heighten impulsivity, making suicide more likely.
D. Homosexuality: Being part of a sexual minority is associated with increased risk of mental health issues and bullying, which can elevate suicide risk. However, homosexuality alone is not a risk factor unless combined with factors such as rejection, isolation, or mental illness.
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