A nurse is assessing an infant with suspected gastroenteritis. Which assessment finding should be reported immediately?
Dry lips and sunken fontanelle
Slightly decreased urine output
Mild irritability during feedings
Occasional vomiting after feeds
The Correct Answer is A
A) Correct. Dry lips and a sunken fontanelle are signs of severe dehydration in an infant and require immediate attention.
B) Incorrect. While decreased urine output is a concern, it may not necessitate immediate reporting if it is only slightly decreased.
C) Incorrect. Mild irritability during feedings is a symptom of discomfort but may not necessitate immediate reporting.
D) Incorrect. Occasional vomiting after feeds is a common symptom of gastroenteritis and may not necessitate immediate reporting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Correct. Severe viral gastroenteritis can lead to malnutrition due to the inability to absorb nutrients properly during the acute phase.
B) Incorrect. Hypernatremia, or high sodium levels, is not a common complication of gastroenteritis.
C) Incorrect. Hypotension, or low blood pressure, may occur in severe cases, but it is not a typical complication during recovery.
D) Incorrect. Urinary retention is not a typical complication of gastroenteritis.
Correct Answer is B
Explanation
A) Incorrect. While stress and anxiety can exacerbate symptoms of GERD, they are not the primary cause. The underlying cause of heartburn in GERD is the reflux of stomach acid into the esophagus.
B) Correct. Heartburn in GERD is caused by the backflow of stomach acid into the esophagus, leading to irritation and discomfort.
C) Incorrect. While spicy foods can trigger heartburn in some individuals, they are not the primary cause of GERD. The underlying issue is the reflux of stomach acid.
D) Incorrect. An overproduction of bile in the stomach is not a direct cause of GERD. The condition is primarily related to the reflux of stomach acid.
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