A nurse is assessing an infant who has water intoxication. Which of the following findings should the nurse expect?

Generalized edema

Elevated urine specific gravity

Thready pulse

Increased hematocrit

Answer and Explanation

The Correct Answer is C

A. Water intoxication can lead to dilutional hyponatremia, which may result in fluid shifting into cells, causing cellular swelling and potentially cerebral edema, but generalized edema is not typically associated with water intoxication.

B. Water intoxication leads to dilution of electrolytes, including sodium, which results in decreased urine specific gravity rather than elevated.

C. Thready pulse is a common finding in water intoxication due to electrolyte imbalances and hemodilution.

D. Increased hematocrit is not typically associated with water intoxication; rather, it may indicate dehydration or hemoconcentration.

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Correct Answer is D

Explanation

A. Dependent edema may occur in some cases of pericarditis but is not typically a priority finding compared to chest pain, which can indicate cardiac compromise.

B. A pericardial friction rub is a classic finding in pericarditis but is not necessarily the priority over the chest pain, which requires immediate attention.

C. A paradoxical pulse (pulse amplitude decreasing during inspiration) can occur in pericarditis but is not typically as concerning as substernal chest pain.

D. Substernal chest pain is a common and significant symptom of pericarditis, and assessing and managing the pain is a priority to ensure adequate cardiac function and alleviate discomfort.

A. Constipation B. Indigestion C. Swollen ankles D. Urinary frequency E. None F. None

Correct Answer is B

Explanation

A. Constipation: While constipation can be uncomfortable, it is not typically considered an immediate threat to a patient's health in a cardiac unit setting. It requires assessment and intervention but is not the highest priority.

B. Indigestion can be a subtle symptom of myocardial infarction (MI) or acute coronary syndrome (ACS), particularly in older adults, women, or clients with diabetes. Clients experiencing "indigestion" may be describing chest discomfort, which requires immediate assessment to rule out a cardiac event. Early identification and intervention for cardiac symptoms are critical to prevent further complications.

C. Swollen ankles can indicate fluid retention, which is a common sign of heart failure. While this symptom requires attention, it does not typically indicate an immediate life-threatening issue compared to potential cardiac ischemia associated with "indigestion."

D. Urinary frequency: This could be related to medications or other conditions. While it should be addressed, it is not the most critical issue compared to potential acute cardiac symptoms.

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A nurse is assessing an infant who has water intoxication. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has pericarditis. Which of the following findings is the priority?

Correct Answer is D

Explanation

At the start of an evening shift on a cardiac unit, a licensed practical nurse brings the nurse a list of client reports. Which of the following client reports should the nurse assess first?

Correct Answer is B

Explanation

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