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 B
Explanation
A. First trimester bleeding. Abruptio placentae typically occurs in the third trimester, not the first. First trimester bleeding is more commonly associated with miscarriage or ectopic pregnancy.
B. Severe abdominal pain. Abruptio placentae involves the premature separation of the placenta from the uterine wall, often leading to sudden, severe abdominal pain and possibly vaginal bleeding. It is a medical emergency requiring immediate attention.
C. Nausea. While nausea can occur during pregnancy, it is not a hallmark symptom of abruptio placentae and does not assist in differentiating it from other complications.
D. Delayed menses. Delayed menses may indicate early pregnancy, but it is not related to abruptio placentae, which occurs later in pregnancy.
Correct Answer is []
Explanation
This client has multiple risk factors for pancreatitis, including type 2 diabetes mellitus, hyperlipidemia, and a history of cardiovascular disease. Although the vital signs are relatively stable, the presence of risk factors and a likely clinical presentation (e.g., abdominal symptoms assumed by context) are consistent with pancreatitis. In acute pancreatitis, the pancreas becomes inflamed and digestive enzymes may attack pancreatic tissue.
NPO status is essential to rest the gastrointestinal tract and reduce pancreatic stimulation. Opioids are typically required due to the severity of abdominal pain. Elevated glucose can result from impaired insulin production due to pancreatic inflammation. Jaundice may occur if the bile duct is obstructed due to pancreatic swelling or inflammation.
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