A nurse is collecting admission history data from a client who is in a semi-private room. Which of the following data is the priority for the nurse to address?

Recent exposure to tuberculosis

History of generalized anxiety disorder

Reports periodic migraine headaches

Experiences nocturia

Answer and Explanation

The Correct Answer is A

Recent exposure to tuberculosis. This is the priority data that the nurse should address as it puts other clients and hospital staff at risk of contracting tuberculosis. Options B, C, and D are not urgent and can be addressed after addressing option A.

Reasons why the other options are not answers:

Option B: A history of generalized anxiety disorder is not an urgent issue that requires the nurse's immediate attention.

Option C: Reports periodic migraine headaches are not an urgent issue that requires the nurse's immediate attention.

Option D: Experiencing nocturia is not an urgent issue that requires the nurse's immediate attention.

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Correct Answer is ["A","D"]

Explanation

The correct answer is Choice A, Choice D.

Choice A rationale: Tachycardia, or an increased heart rate, is a common symptom of dehydration in infants. The body attempts to maintain adequate blood circulation despite reduced fluid volume by increasing the heart rate, which is a compensatory mechanism.

Choice B rationale: Bloating is not typically associated with dehydration in infants. Dehydration usually results in symptoms like dry mucous membranes and decreased skin turgor, rather than gastrointestinal symptoms like bloating.

Choice C rationale: Hypertension, or high blood pressure, is uncommon in dehydrated infants. Dehydration generally leads to hypotension (low blood pressure) due to decreased fluid volume in the circulatory system, which can result in reduced blood pressure.

Choice D rationale: Irritability is a frequent symptom of dehydration in infants. Reduced fluid intake and electrolyte imbalances can cause discomfort and distress, leading to irritability and increased fussiness in dehydrated infants.

A. Use the nondominant hand to pull the skin and subcutaneous tissue 2.5 cm (1 in) laterally. B. Remove the needle and release the tissue. C. Aspirate by pulling back on the plunger and inject the medication.

Correct Answer is A,C,B

Explanation

Here’s the correct sequence for administering ceftriaxone using the Z-track technique: 1. Use the nondominant hand to pull the skin and subcutaneous tissue 2.5 cm (1 in) laterally. 2. Aspirate by pulling back on the plunger and inject the medication. 3. Remove the needle and release the tissue. This method helps to prevent the medication from leaking into the subcutaneous tissue, reducing irritation and discomfort.

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A nurse is collecting admission history data from a client who is in a semi-private room. Which of the following data is the priority for the nurse to address?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following symptoms should a nurse expect to find when assessing an infant who is dehydrated in an emergency department? Select all that apply

Correct Answer is ["A","D"]

Explanation

Correct Answer is A,C,B

Explanation

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