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. This response may appear dismissive or confrontational rather than informative.
B. This response may appear dismissive or confrontational rather than informative.
C. The nurse should not assume whether the client will benefit from reviewing their notes.
D. Under HIPAA regulations, clients have the right to access their medical records, but psychotherapy notes (separate from general treatment records) are typically excluded from disclosure.
Correct Answer is C
Explanation
A. Biological response modifiers (e.g., TNF inhibitors) help manage RA by modifying immune responses, but they increase the risk of infection, not prevent it.
B. Cold therapy should not be applied directly to the skin—it should be wrapped in a towel to prevent skin damage. Cold therapy is used for acute inflammation, not stiffness.
C. Heat therapy, such as a hot shower or warm compress, helps reduce morning stiffness and joint pain in clients with rheumatoid arthritis (RA).
D. Clustered activity can lead to fatigue. Instead, activities should be spread out with rest periods.
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