A 3-week-old infant is admited to the pediatric unit with vomiting and dehydration. The mother describes the infant as having projectile vomiting after eating. She also tells the practical nurse (PN) that the baby is always hungry. Which finding warrants immediate intervention by the PN?
Hyperactive gastric sounds.
Irregular palpable pulse.
Crying without tears.
Underweight for age.
The Correct Answer is B
This finding may indicate a potential cardiac issue that needs immediate medical atention. Projectile vomiting and excessive hunger in a young infant may be signs of pyloric stenosis, a condition in which the muscle between the stomach and small intestine thickens, making it difficult for food to pass through.
Hyperactive gastric sounds may be present with vomiting, but it is not an immediate concern.
Crying without tears may be a sign of dehydration, but it is not an immediate concern.
Underweight for age is a concern but it is not a finding that requires immediate intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The practical nurse should report to the charge nurse that the client is near delivery, as the client's signs indicate that she is in the transition phase of labor and is likely to deliver soon. The PN should also assess the client's vital signs, fetal heart rate, and pain level, and prepare the delivery equipment.
The husband can be asked to provide emotional support to the client during labor.
The rapid response team may be called in case of a medical emergency, but this is not indicated based on the information given.
Checking the time, the last PRN narcotic analgesic was given is also not indicated at this point, as the client is close to delivery and may not have time for medication to take effect.
Correct Answer is A
Explanation
A male client with paranoia can be expected to exhibit behavior such as being **openly hostile to others for no apparent reason**. Paranoia is a mental health condition characterized by intense and irrational mistrust or suspicion of others. This can lead to hostility and aggression towards others, even when there is no apparent reason for it.
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