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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: This is not a good choice. Delaying dental visits until the child's heart defect is fully repaired is not a recommended practice. Dental hygiene is important for preventing oral infections that can spread to the bloodstream and cause infective endocarditis. The child should have regular dental check-ups and cleanings, as well as good oral care at home.
Choice B reason: This is the correct choice. Administration of antibiotics one hour prior to all dental procedures is a critical teaching point to emphasize for parents of a child with a complex congenital heart defect. Dental procedures can cause bleeding and bacteria to enter the bloodstream, which can infect the damaged or abnormal heart valves and cause infective endocarditis. Antibiotics can prevent or reduce the risk of this complication by killing the bacteria before they reach the heart.
Choice C reason: This is not a good choice. Administration of daily prophylactic antibiotics is not a necessary or effective measure for preventing infective endocarditis in a child with a complex congenital heart defect. Daily antibiotics can cause side effects, such as allergic reactions, diarrhea, or yeast infections. They can also lead to antibiotic resistance, which can make the bacteria harder to treat if they do cause an infection.
Choice D reason: This is not a good choice. High dose IV antibiotics for 2-8 weeks is not a preventive strategy for infective endocarditis, but a treatment option for an established infection. IV antibiotics are given to eradicate the bacteria from the bloodstream and the heart valves and prevent further damage or complications. However, IV antibiotics are not always effective and may have serious s
Correct Answer is C
Explanation
Choice A reason: This statement is incorrect, as maceration is not a clinical manifestation of scabies, but a condition of softening and breaking down of the skin due to prolonged exposure to moisture. Maceration can occur in areas where the skin folds or rubs together, such as the groin, armpits, or under the breasts.
Choice B reason: This statement is incorrect, as edema is not a clinical manifestation of scabies, but a condition of swelling due to excess fluid accumulation in the tissues. Edema can occur in various parts of the body, such as the legs, feet, hands, or face, due to various causes, such as heart failure, kidney disease, or allergic reactions.
Choice C reason: This statement is correct, as itching is the primary clinical manifestation of scabies, a contagious skin infection caused by the mite Sarcoptes scabiei. The mite burrows into the skin and lays eggs, causing an intense inflammatory response and pruritus. The itching is usually worse at night and affects the areas between the fingers, wrists, elbows, armpits, waist, buttocks, and genitals.
Choice D reason: This statement is incorrect, as severe pain is not a clinical manifestation of scabies, but a subjective sensation of physical discomfort or distress. Pain can occur in various parts of the body due to various causes, such as injury, inflammation, infection, or disease. Pain can be acute or chronic, and can be rated on a scale of 0 to 10.
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