A nurse in an urgent care clinic is caring for an infant who presents with vomiting, diarrhea, and decreased oral intake. Which of the following manifestations should the nurse expect?
Bulging anterior fontanel
Decreased temperature
Hypertension
Oliguria
The Correct Answer is D
A. Bulging anterior fontanel. A bulging fontanel is associated with increased intracranial pressure, not dehydration. Dehydration is more likely to cause a sunken fontanel.
B. Decreased temperature. Dehydrated infants typically exhibit normal or elevated temperatures, especially if they have an underlying infection or fever. A decreased temperature is not a common sign of dehydration.
C. Hypertension. Dehydration more commonly leads to hypotension or normal blood pressure, depending on severity. Hypertension is not an expected finding in an infant with fluid volume loss.
D. Oliguria. Decreased urine output (oliguria) is a classic and expected sign of dehydration in infants. It indicates the kidneys are conserving fluid due to inadequate intake and fluid loss from vomiting and diarrhea.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "Why are you eating seaweed soup?" This response is judgmental and dismissive of the client’s cultural practices. It can make the client feel misunderstood or disrespected.
B. "The hospital food is more nutritious for you." This statement is inaccurate and culturally insensitive, assuming that hospital food is superior without recognizing the nutritional and emotional value of traditional foods.
C. "Does the doctor know that you are eating that?" This implies unnecessary medical concern and may make the client feel like her personal choices require approval, which can be disempowering and disrespectful.
D. "Of course, I will heat that up for you." This response is supportive and culturally competent, respecting the client's traditions and preferences while promoting comfort and emotional well-being during the postpartum period.
Correct Answer is B
Explanation
A. Delayed. Delayed grief is characterized by the postponement or suppression of grieving responses, often surfacing long after the loss has occurred. It does not apply here, as the family member is expressing active emotional struggle before the loss.
B. Anticipatory. Anticipatory grief occurs before an actual loss, such as when a loved one is dying from a terminal illness. The family member is beginning to grieve the impending death and the emotional impact of the future loss, which fits this type of grief.
C. Disenfranchised. Disenfranchised grief refers to grief that is not openly acknowledged or socially supported, such as the death of an ex-partner or a pet. In this scenario, the grief is acknowledged and supported, so this does not apply.
D. Exaggerated. Exaggerated grief involves intense symptoms that interfere with daily functioning, such as severe depression, phobias, or suicidal thoughts. The family member is expressing difficulty, but not at a level that indicates dysfunction.
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