The nurse is reviewing the intake and output record from the previous 8 hours for an infant admitted with dehydration.
The nurse also reviews the most recent lab results in the chart.
Based on the information in the chart, what does the nurse determine about this patient during the shift?
Option A
Option B
Option C
Option D
The Correct Answer is A
Choice A rationale
Dehydration in infants can be a serious medical concern if not addressed quickly. It can be caused by various factors such as vomiting or diarrhea, or if the baby is not nursing well. The most common signs of dehydration in babies include concentrated urine that looks very dark yellow or orange, constipation, dry lips, dry mouth, dry mucous membranes, excessive sleepiness, irritability, less than six wet diapers in a 24-hour period, no interest in taking a bottle or breastfeeding, no tears when crying, paleness, sunken fontanelle (soft spot) on their head, and wrinkled skin. If the nurse observes these signs and symptoms in the infant, along with the intake and output record from the previous 8 hours, the nurse might determine that the patient is dehydrated during the shift.
Choice B rationale
If the infant shows signs of improvement such as increased urine output, normal skin turgor, moist mucous membranes, and the infant is alert and active, then the nurse might determine that the patient is improving as anticipated. However, without specific details about the infant’s condition, it’s difficult to definitively say that this is the case.
Choice C rationale
Fluid volume excess, also known as fluid overload, occurs when the body has too much water and electrolytes. Symptoms can include swelling in the hands, feet, ankles, or abdomen, weight gain, high blood pressure, and shortness of breath. If the nurse observes these symptoms in the infant, along with the intake and output record from the previous 8 hours, the nurse might
determine that the patient has fluid volume excess. However, given the information provided, this does not seem to be the most likely scenario.
Choice D rationale
If the infant’s vital signs are stable, the infant is alert and active, and there are no significant changes in the infant’s condition, the nurse might determine that the patient’s condition is stable. However, without specific details about the infant’s condition, it’s difficult to definitively say that this is the case.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Adequate intake is crucial for hydration, but the information provided does not specify the infant’s intake.
Choice B rationale
Adequate output is a good sign of hydration, but the information provided does not specify the infant’s output.
Choice C rationale
Normal lab results could indicate adequate hydration, but the information provided does not specify the infant’s lab results.
Choice D rationale
The infant was admitted with dehydration, and without information on improved intake or output, it is reasonable to conclude that the infant’s lab results indicated dehydration.
Correct Answer is A
Explanation
Choice A rationale
Providing interdisciplinary care that is comprehensive is a key aspect of patient-centered care and the medical home model. This approach involves a team of healthcare professionals from various disciplines working together to provide comprehensive care. It ensures that all aspects of a patient’s health are considered and addressed, leading to more effective and efficient care.
Choice B rationale
Empowering families to make decisions is an important aspect of patient-centered care, but it is not the key aspect of the medical home model. While patient and family empowerment is crucial for ensuring that care aligns with the patient’s values and preferences, the medical home model’s primary focus is on providing comprehensive, coordinated care.
Choice C rationale
Offering supportive and holistic care approaches to treat the child is an important aspect of patient-centered care, but it is not the key aspect of the medical home model. While these approaches can enhance the quality of care and patient satisfaction, the medical home model’s main focus is on providing comprehensive, coordinated care.
Choice D rationale
Taking responsibility for care when needed is an important aspect of patient-centered care, but it is not the key aspect of the medical home model. While healthcare providers must be ready to take responsibility for care when necessary, the medical home model’s primary focus is on providing comprehensive, coordinated care.
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