A nurse is caring for an infant who has gastroenteritis. Which of the following assessment findings should the nurse report to the provider?
Pale and a 24-hr fluid deficit of 30 mL
Decreased appetite and irritability
Temperature 38° C (100.4° F) and pulse rate 124/min
Sunken fontanels and dry mucous membranes
The Correct Answer is D
A. Incorrect – A 24-hour fluid deficit of 30 mL is mild and does not require immediate intervention.
B. Incorrect – Decreased appetite and irritability are common with gastroenteritis but not as concerning as dehydration.
C. Incorrect – A temperature of 38°C (100.4°F) and pulse of 124/min are mild and expected with infection.
D. Correct – Sunken fontanels and dry mucous membranes are signs of dehydration, which is a major concern in gastroenteritis. Severe dehydration can lead to hypovolemic shock.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Prednisone should be taken with food to prevent gastrointestinal irritation.
B. Weight gain, not weight loss, is a common side effect due to fluid retention and increased appetite.
C. Prednisone should be taken in the morning, as it can cause insomnia if taken at bedtime.
D. Prednisone is a corticosteroid that increases the risk of osteoporosis by reducing calcium absorption, so clients should increase dietary calcium and vitamin D intake.
Correct Answer is C
Explanation
A. While male gender is associated with a higher likelihood of violence, it is not the best predictor.
B. A history of being in prison suggests past criminal behavior but does not necessarily indicate violence.
C. A history of violent behavior is the strongest predictor of future violence.
D. Delusions may contribute to violent behavior, but not all individuals with delusions act violently.
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