A nurse is caring for a 6-month-old infant who has acute vomiting and diarrhea. Which of the following manifestations should the nurse identify as an indication of moderate hypovolemia?
Capillary refill greater than 4 seconds
Bradycardia
Tachypnea
Lethargy
The Correct Answer is C
A. Capillary refill greater than 4 seconds: This indicates severe hypovolemia, not moderate.
B. Bradycardia: Bradycardia is uncommon in hypovolemia and may occur late as a sign of decompensation, especially in infants.
C. Tachypnea. Tachypnea is a compensatory response to hypovolemia as the body attempts to improve oxygenation and circulation.
D. Lethargy: While lethargy is a concerning sign, it is associated with more severe dehydration than moderate hypovolemia.
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Related Questions
Correct Answer is A
Explanation
A. A 15-year-old client who requires an open reduction of a fracture. Minors generally require parental or guardian consent for surgical procedures unless emancipated.
B. While an infant cannot consent, IV antibiotics are considered a routine medical treatment. General consent for treatment is usually signed upon admission to the hospital, which covers standard nursing interventions like starting an IV or administering prescribed medications. Specific informed consent forms are typically reserved for higher-risk procedures (surgeries, blood transfusions, etc.).
C. In most jurisdictions, minors can provide their own consent for medically emancipatedconditions. These typically include prenatal care, contraception, testing and treatment for STIs, and substance abuse treatment. The nurse would not need to obtain consent from a guardian in this specific context to protect the minor's privacy and access to care.
D. A chest x-ray is a non-invasive diagnostic procedure. Similar to the administration of medications, these are covered under the general consent for treatment signed at the time of admission. They do not require a separate, formal informed consent document for each individual imaging study.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
Explanation
The infant is at risk for developing aspiration pneumonia and esophageal strictures.
Rationale:
- Aspiration pneumonia: GER can cause stomach contents to enter the respiratory tract, leading to aspiration pneumonia.
- Esophageal strictures: Chronic irritation from stomach acid can result in scarring and narrowing of the esophagus.
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