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 C
Explanation
Choice A reason: This statement is incorrect, as Airborne Precautions are not indicated for patients with LIP, unless they have other infections that are transmitted by airborne particles, such as tuberculosis, measles, or chickenpox. Airborne Precautions include wearing a respirator or N95 mask when entering the patient's room, placing the patient in a negative-pressure isolation room with the door closed, and limiting the movement of the patient outside the room.
Choice B reason: This statement is incorrect, as LIP is not rarely seen in children with AIDS, but rather one of the most common pulmonary complications of HIV infection in children. LIP affects about 30% to 40% of children with HIV, and is more prevalent in younger children than older children or adults.
Choice C reason: This statement is correct, as LIP is a common AIDS-defining condition in children with HIV. AIDS-defining conditions are illnesses that occur in people with advanced HIV infection and indicate a severe immunosuppression. LIP is a chronic inflammatory disorder of the lungs that causes lymphocytic infiltration of the interstitium and alveoli, leading to respiratory symptoms and impaired gas exchange.
Choice D reason: This statement is incorrect, as antibiotics are not the first-line treatment for LIP, unless there is a bacterial superinfection. Antibiotics do not target the underlying cause of LIP, which is the HIV infection and the associated immune dysfunction. The main treatment for LIP is antiretroviral therapy (ART), which suppresses the viral replication and improves the immune status of the patient. Corticosteroids may also be used to reduce the inflammation and improve the lung function.
Correct Answer is D
Explanation
Choice A reason: This statement is incorrect, as burping the infant after feeding is not a nursing intervention, but a normal practice to prevent gas and discomfort. The nurse should encourage the mother to burp the infant gently after each feeding, and to avoid overfeeding or underfeeding the infant.
Choice B reason: This statement is incorrect, as giving five milliliters of water is not a nursing intervention, but a harmless amount of fluid for the infant. The nurse should inform the mother that water is not necessary for the infant, as breast milk or formula provides enough hydration and nutrition. However, the nurse should also reassure the mother that a small amount of water will not harm the infant.
Choice C reason: This statement is incorrect, as wrapping the infant during feeding is not a nursing intervention, but a comforting measure for the infant. The nurse should support the mother's bonding with the infant, and suggest ways to make the feeding experience more pleasant and relaxing for both of them. The nurse should also monitor the infant's temperature and avoid overheating.
Choice D reason: This statement is correct, as giving thirty milliliters of water is a nursing intervention that indicates a need for further education and guidance. The nurse should explain to the mother that giving too much water to the infant can cause water intoxication, which can lead to hyponatremia, seizures, or even death. The nurse should also teach the mother the signs and symptoms of water intoxication, such as irritability, lethargy, vomiting, or swelling.
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