When assessing an infant with moderate dehydration, a nurse would expect which assessment findings?
Fever and hypertension.
Increased specific gravity.
Tachypnea and tachycardia.
Bulging posterior fontanel.
The Correct Answer is C
Choice A rationale:
Fever and hypertension are not typical findings in moderate dehydration. Dehydration often leads to hypotension rather than hypertension, and fever is not a direct consequence of dehydration.
Choice B rationale:
Increased specific gravity can be a sign of dehydration, but it is not as specific or sensitive as tachypnea (rapid breathing) and tachycardia (elevated heart rate), which occur due to the body's compensatory mechanisms in response to dehydration.
Choice C rationale:
Tachypnea and tachycardia are key indicators of moderate dehydration in infants. The body tries to maintain perfusion by increasing the heart rate and respiratory rate. These signs are more reliable indicators of dehydration than specific gravity or fever.
Choice D rationale:
Bulging posterior fontanel is not a typical finding in dehydration. A sunken fontanel might be more indicative of dehydration, as fluid shifts from the intracellular to the extracellular space.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Placing the patient in halo traction is not applicable for a scoliosis correction surgery with Harrington rods. Halo traction is typically used for cervical spine injuries or deformities, not for scoliosis correction.
Choice B rationale:
The correct answer. After Harrington rod insertion, maintaining proper alignment is crucial to prevent complications. Using a log-roll technique when turning the patient helps maintain spinal alignment and prevent stress on the surgical site.
Choice C rationale:
Keeping the patient nothing by mouth for 72 hours is not typically necessary after scoliosis surgery. Clear fluids and a light diet are usually initiated shortly after surgery.
Choice D rationale:
Restricting visitors for 48 hours is not a standard practice after scoliosis surgery unless there are specific infection control concerns, which are not mentioned in the scenario.
Correct Answer is C
Explanation
Choice A rationale:
Threat to body image is not the primary concern for an 8-year-old patient undergoing diagnostic testing for seizures. Seizures are primarily neurological in nature.
Choice B rationale:
Fear of bodily injury might be a concern, but for an 8-year-old patient undergoing diagnostic testing for seizures, the more immediate concern would likely be related to their social interactions and acceptance among peers.
Choice C rationale:
Loss of peer acceptance is the most likely psychological concern for an 8-year-old patient during diagnostic testing. Children at this age are highly conscious of fitting in with their peers, and a medical condition might make them worry about being different.
Choice D rationale:
Separation from parents could be a concern for younger children, but 8-year-olds are generally more independent and less likely to experience extreme separation anxiety.
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