A nurse is collecting data from an infant who has gastroesophageal reflux. Which of the following findings should the nurse expect? (Select the 3 that apply.)
Wheezing
Rigid abdomen
Pallor
Weight loss
Vomiting
Correct Answer : A,D,E
A. Wheezing: Wheezing is a common symptom associated with asthma, which can be exacerbated by gastroesophageal reflux (GER) in infants. GER occurs when stomach contents flow back into the esophagus, leading to irritation and inflammation of the airways. This inflammation can cause wheezing sounds during breathing, especially if the refluxed material reaches the lower respiratory tract.
B. Rigid abdomen: While gastroesophageal reflux (GER) primarily affects the upper gastrointestinal tract, it typically does not cause a rigid abdomen. A rigid abdomen may indicate other underlying gastrointestinal issues such as bowel obstruction, intussusception, or peritonitis. These conditions are not typically associated with GER in infants.
C. Pallor: Pallor, or paleness of the skin, is not a common symptom of gastroesophageal reflux (GER) in infants. GER primarily affects the upper gastrointestinal tract and is characterized by symptoms such as spitting up, regurgitation, and irritability. Pallor may be indicative of other health issues such as anemia or circulatory problems but is not directly related to GER.
D. Weight loss: Weight loss can occur in infants with gastroesophageal reflux (GER) if frequent vomiting leads to inadequate intake of nutrients. However, it is not a direct symptom of GER itself. Infants with GER may experience feeding difficulties, irritability, and discomfort associated with feeding, which can contribute to poor weight gain over time if not managed effectively.
E. Vomiting: Vomiting is a common symptom of gastroesophageal reflux (GER) in infants. It occurs when stomach contents flow back up into the esophagus and sometimes out of the mouth. Infants with GER may spit up or vomit frequently after feeding or during burping, which can lead to discomfort and irritability. Vomiting may also contribute to poor weight gain and nutritional deficiencies if not managed effectively.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E"]
Explanation
A. Hematuria:
Hematuria, or blood in the urine, is a common finding in urinary tract infections (UTIs). It occurs due to irritation and inflammation of the urinary tract lining, causing small blood vessels to leak blood into the urine.
B. Urinary frequency:
Urinary frequency, or the need to urinate more often than usual, is a classic symptom of a UTI. It occurs because the infection irritates the bladder lining, leading to a frequent urge to urinate even when the bladder is not full.
C. Polyuria:
Polyuria, or excessive urination, is not typically associated with uncomplicated urinary tract infections. Instead, UTIs usually cause urinary frequency without necessarily increasing the total volume of urine produced (polyuria).
D. Dependent edema:
Dependent edema, or swelling in the lower extremities due to fluid accumulation, is not a typical finding in urinary tract infections. UTIs primarily affect the urinary system and do not typically cause systemic fluid retention.
E. Dysuria:
Dysuria, or painful urination, is another hallmark symptom of urinary tract infections. It occurs due to inflammation and irritation of the urinary tract lining, making urination uncomfortable or even painful.
Correct Answer is C
Explanation
A. Maintain seizure precautions:
While seizures can occur as a complication of bacterial meningitis, maintaining seizure precautions is not the nurse's priority at this stage. Prompt administration of antibiotics to address the underlying infection takes precedence over seizure precautions.
B. Document intake and output:
Documenting intake and output is an important nursing responsibility, but it is not the priority when a child is suspected of having bacterial meningitis. The immediate priority is to initiate antibiotic therapy to treat the infection and prevent further complications.
C. Administer antibiotics when available:
Administering antibiotics is the priority in the care of a child with suspected bacterial meningitis. Antibiotics are crucial for treating the infection and preventing its progression to reduce the risk of serious complications such as brain damage or death.
D. Reduce environmental stimuli:
While reducing environmental stimuli can help manage symptoms and discomfort in a child with bacterial meningitis, it is not the priority at this time. Initiating antibiotic therapy is essential to address the underlying infection, which takes precedence over environmental stimuli reduction.
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