A nurse is caring for a 3-month-old infant who has gastroenteritis and is receiving monitoring for dehydration. For which of the following findings should the nurse monitor?
Bulging fontanel
Weight loss
Distended jugular vein
Bradycardia
The Correct Answer is B
A. Bulging fontanel: A bulging fontanel typically indicates increased intracranial pressure, not dehydration. In dehydration, the fontanel is more likely to appear sunken in infants, making this an incorrect finding to monitor for fluid loss.
B. Weight loss: Weight loss is a key indicator of fluid loss in infants. Monitoring daily weight provides an objective measure of dehydration severity and effectiveness of rehydration interventions, making it a critical finding for the nurse to track.
C. Distended jugular vein: Jugular vein distention is associated with fluid overload or cardiac issues, not dehydration. This finding would be unlikely in a 3-month-old infant with gastroenteritis.
D. Bradycardia: Dehydration in infants typically presents with tachycardia as the body compensates for decreased fluid volume. Bradycardia is not a common sign of dehydration and may indicate another underlying condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "You should increase your daily fluid intake.": Adequate hydration is important during early pregnancy to support maternal blood volume expansion, amniotic fluid production, and overall health. Increasing fluid intake can also help alleviate common symptoms such as constipation and mild nausea.
B. "Headaches are expected throughout pregnancy.": While mild headaches can occur, persistent or severe headaches are not considered normal and may indicate complications such as hypertension. Clients should be advised to report significant or recurrent headaches to their provider.
C. "You will feel your baby moving within the next month.": Fetal movement, or “quickening,” typically occurs between 16–20 weeks of gestation for primigravid clients, not at 9–10 weeks. Early reassurance should focus on expected developmental milestones for this stage.
D. "Hormone shifts often cause severe vomiting.": Mild nausea and vomiting are common in early pregnancy due to hormonal changes, but severe vomiting (hyperemesis gravidarum) is not expected and requires medical evaluation for hydration and nutritional management.
Correct Answer is A
Explanation
A. Denial: Denial is an expected initial stage of grief in response to terminal illness. Clients may have difficulty accepting the diagnosis and may refuse to believe the reality of their condition as a coping mechanism.
B. Reorganization: Reorganization is a later stage of grief associated with adapting to loss after bereavement. It is not typically part of the immediate response to a terminal diagnosis in the dying process.
C. Numbing: Numbing is more commonly associated with acute grief reactions following sudden loss, rather than the anticipatory grief experienced after a terminal diagnosis.
D. Reinvesting: Reinvesting refers to redirecting emotional energy into new relationships or activities after loss. This stage occurs after bereavement and is not part of the expected stages of grief during the dying process.
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