A nurse is reviewing the medical record of a toddler who has moderate dehydration. Which of the following findings should the nurse expect?
Decreased hematocrit
Increased respiratory rate
Decreased heart rate
Increased platelet count
The Correct Answer is B
A. Decreased hematocrit: Hematocrit usually increases in dehydration due to the concentration of red blood cells in a smaller volume of plasma.
B. Increased respiratory rate: Dehydration can lead to tachypnea (increased respiratory rate) as the body attempts to compensate for the decreased blood volume and maintain oxygen delivery.
C. Decreased heart rate: Dehydration typically causes tachycardia (increased heart rate) as the body tries to maintain adequate blood circulation and pressure.
D. Increased platelet count: Dehydration does not typically affect platelet count significantly, though it may concentrate blood components, including platelets, making them appear elevated on a lab test.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Brisk pupillary reaction to light: A brisk pupillary reaction to light is a normal neurological finding and does not indicate increased ICP. Increased ICP might present with a sluggish or unequal pupil response.
B. Irritability: Irritability is a common early sign of increased ICP in infants. Changes in behaviour, such as increased irritability or lethargy, can indicate a neurological problem, including increased pressure within the skull.
C. Tachycardia: Tachycardia (increased heart rate) is not a typical indicator of increased ICP. Bradycardia (decreased heart rate) is more commonly associated with increased ICP due to the pressure on the brainstem affecting autonomic functions.
D. Increased sensory response to painful stimuli: Increased sensory response is not typically indicative of increased ICP. In fact, as ICP worsens, a decrease in sensory response or altered level of consciousness is more likely.
Correct Answer is B
Explanation
A. Perform range-of-motion (ROM) exercises to the infant's hips. ROM exercises are not the priority for an infant with spina bifida and could potentially cause harm if not done properly, particularly if the lesion is in a sensitive area.
B. Place the infant in a prone position. This is the correct action as it helps prevent pressure on the spina bifida lesion and minimizes the risk of injury or infection to the exposed spinal cord or meninges.
C. Feed the infant through an NG tube. An NG tube is not typically necessary for feeding infants with spina bifida unless there are other complicating factors that affect feeding.
D. Cover the infant's lesion with a dry cloth. The lesion should be covered with a sterile, moist, and non-adhesive dressing to prevent infection and keep the area moist. A dry cloth could cause the lesion to dry out and increase the risk of infection or damage.
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