An infant is brought to the emergency department with poor skin turgor, weight loss, irritability, and tachycardia. The nurse analyzes the data to suggest:

Sodium excess

Overhydration

Dehydration

Calcium excess

Answer and Explanation

The Correct Answer is C

Choice A reason: This statement is incorrect, as sodium excess is not likely to cause the symptoms of poor skin turgor, weight loss, irritability, and tachycardia in an infant. Sodium excess, or hypernatremia, is a condition where the blood sodium level is too high, which can result from excessive intake or loss of water. The symptoms of sodium excess may include thirst, dry mouth, confusion, seizures, or coma.

Choice B reason: This statement is incorrect, as overhydration is not likely to cause the symptoms of poor skin turgor, weight loss, irritability, and tachycardia in an infant. Overhydration, or hypervolemia, is a condition where the body has too much fluid, which can result from excessive intake or retention of water. The symptoms of overhydration may include edema, weight gain, shortness of breath, or crackles in the lungs.

Choice C reason: This statement is correct, as dehydration is the most likely cause of the symptoms of poor skin turgor, weight loss, irritability, and tachycardia in an infant. Dehydration is a condition where the body loses more fluid than it takes in, which can result from vomiting, diarrhea, fever, or inadequate intake of water. The symptoms of dehydration may include dry skin, sunken eyes, decreased urine output, or lethargy.

Choice D reason: This statement is incorrect, as calcium excess is not likely to cause the symptoms of poor skin turgor, weight loss, irritability, and tachycardia in an infant. Calcium excess, or hypercalcemia, is a condition where the blood calcium level is too high, which can result from hyperparathyroidism, malignancy, or excessive intake of vitamin D or calcium. The symptoms of calcium excess may include nausea, constipation, muscle weakness, or kidney stones.

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Correct Answer is D

Explanation

Choice A reason: This statement is incorrect, as Tanner staging is not based on chronological age, but on the physical development of the child. Children may enter and progress through puberty at different ages, depending on their genetic, environmental, and nutritional factors.

Choice B reason: This statement is incorrect, as Tanner staging is not based on the sexual behavior of the child, but on the appearance of the external genitalia, breasts, and pubic hair. Sexual behavior is influenced by many factors, such as social, cultural, and psychological factors, and does not necessarily correlate with the stage of puberty.

Choice C reason: This statement is incorrect, as Tanner staging is not based on the increase in height and weight, but on the maturation of the reproductive organs and secondary sex characteristics. Height and weight are affected by many factors, such as nutrition, health, and genetics, and do not necessarily reflect the stage of puberty.

Choice D reason: This statement is correct, as Tanner staging is based on the predictable stages of puberty that are based on primary and secondary sexual characteristics. Primary sexual characteristics are the development of the internal and external reproductive organs, such as the ovaries, testes, uterus, penis, and vagina. Secondary sexual characteristics are the changes that occur in other parts of the body, such as the breasts, pubic hair, axillary hair, voice, and body shape.

A. Axillary temperature of 37.3° C B. Mild abdominal pain C. BP of 100/54 D. Currant jelly stools

Correct Answer is D

Explanation

Choice A reason: This is incorrect because an axillary temperature of 37.3° C is within the normal range for a 10-month-old child. It does not indicate any infection or complication after the surgery.

Choice B reason: This is incorrect because mild abdominal pain is expected after the surgery and can be managed with analgesics. It does not require immediate notification to the MD.

Choice C reason: This is incorrect because a BP of 100/54 is normal for a 10-month-old child. It does not indicate any shock or hemorrhage after the surgery.

Choice D reason: This is correct because currant jelly stools, which are stools mixed with blood and mucus, are a sign of intussusception, which is a telescoping of the bowel that causes obstruction and inflammation. Currant jelly stools after the surgery indicate that the intussusception has recurred and requires immediate intervention. The nurse should notify the MD and prepare the child for another surgery.

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An infant is brought to the emergency department with poor skin turgor, weight loss, irritability, and tachycardia. The nurse analyzes the data to suggest:

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Naxlex Comprehensive Predictor Exams

The nurse is explaining Tanner staging to an adolescent and her mother. Which statement best describes Tanner staging?

Correct Answer is D

Explanation

Which assessment finding would cause the nurse to notify the MD immediately when assessing a 10-month-old child who had emergency reduction for intussusception 10 hours previously?

Correct Answer is D

Explanation

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