A nurse in an emergency department is assessing an infant who is dehydrated. Which of the following findings should the nurse expect?
Irritability
Tetany
slow, bounding pulse
Decreased temperature
The Correct Answer is A
The nurse should expect to find irritability in an infant who is dehydrated. Dehydration in infants can lead to changes in behavior and irritability due to the imbalance in fluid and electrolytes. Other common signs of dehydration in infants may include:
Poor skin turgor (skin tenting)
Sunken fontanelles (soft spots on the baby's head)
Dry mucous membranes (dry mouth and tongue)
Decreased urine output or concentrated urine
Rapid heart rate (tachycardia)
Increased respiratory rate
Sunken eyes
Decreased tears when crying

B. Tetany is a condition characterized by involuntary muscle contractions and is more commonly associated with hypocalcemia (low calcium levels) rather than dehydration.
C. A slow, bounding pulse is not typically associated with dehydration. Dehydration often leads to a rapid heart rate (tachycardia) as the body attempts to compensate for the loss of fluid.
D. Decreased temperature is not a typical finding in dehydration. Dehydration can lead to fever in some cases due to an underlying infection, but it does not cause a decrease in body temperature on its own.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Following a cardiac catheterization, the nurse should provide the parent with appropriate discharge instructions to ensure the child's proper recovery. The correct instruction to include is option B: "Give the child acetaminophen for discomfort."
Explanation:
Option A: Offering the child clear liquids for the first 24 hours is not a typical instruction following a cardiac catheterization. After the procedure, the child may be allowed to resume a regular diet, as tolerated, based on the healthcare provider's orders.
Option B: This is the correct instruction. After cardiac catheterization, the child may experience some discomfort at the insertion site or the area where the catheter was threaded through the blood vessels. Acetaminophen can be used to manage mild pain or discomfort.
Option C: Taking a tub bath for the first 3 days is not typically mentioned in discharge instructions after a cardiac catheterization. The nurse might advise the parent to avoid submerging the catheter insertion site in water for a specific period and instead use sponge baths until permitted by the healthcare provider.
Option D: Keeping the child home for 1 week is not a standard recommendation for a cardiac catheterization. The recovery period after a cardiac catheterization is usually shorter, and the child can often resume normal activities within a day or two, depending on the specific circumstances of the procedure and the child's condition.
The nurse should thoroughly review the specific discharge instructions provided by the healthcare provider and ensure the parent understands the care required at home, including any restrictions on activities or signs of potential complications that require immediate attention.
Correct Answer is A
Explanation
The nurse should recommend bananas as a safe food choice for a 2-year-old child. Bananas are soft and easy to chew, making them safe for young children. They do not pose a choking hazard, unlike grapes, raw carrots, or celery.
Option B (Grapes) can be a choking hazard for young children, especially if they are not cut into small pieces or are given whole.
Option C (Raw carrots) and Option D (Celery) are hard and crunchy, and they require more chewing, which may not be safe for a 2-year-old child who is still developing their chewing and swallowing abilities.
As a general guideline, when selecting foods for young children, it is essential to choose soft, easily chewable, and non-choking hazard options to promote safe eating and reduce the risk of choking incidents.
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