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

Tachycardia.

Bloating.

Hypertension.

Irritability.

Answer and Explanation

Correct Answer : A,D

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.

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Correct Answer is D

Explanation

This response indicates that the client understands that sudden jaw pain can be a sign of a heart attack and requires immediate medical attention.

A. "I will take four nitroglycerin sublingual tablets if I have chest pain." This is an incorrect statement because taking four nitroglycerin sublingual tablets can lead to hypotension and can be life-threatening.

B. "I will have hot, dry, and flushed skin if I am having a heart attack." This is an incorrect statement because hot, dry, and flushed skin is not a typical sign of a heart attack.

C. "I will wait 30 minutes before taking action if I have heartburn." This is an incorrect statement because heartburn is not a symptom of angina and waiting 30 minutes to take action can lead to further complications.

Explanation: The client with angina should be educated about the signs and symptoms of a heart attack and when to seek medical attention. Jaw pain is one of the signs of a heart attack, and the client should seek emergency medical attention immediately.

A. Obtain a set of vital signs. B. Flex the client's knees and hips. C. Apply a moist saline dressing to the area. D. Elevate the head of the client's bed 20°.

Correct Answer is C

Explanation

The correct answer is c. Apply a moist saline dressing to the area.

Choice A reason: Obtaining a set of vital signs is important, but it is not the immediate priority in this situation. The vital signs will not address the protruding organs directly.

Choice B reason: Flexing the client’s knees and hips may provide comfort but does not directly address the issue of the open incision and protruding organs.

Choice C reason: Applying a moist saline dressing to the area is the correct action. It helps to protect the protruding organs by keeping them moist and reduces the risk of organ damage or infection. This is the priority action to keep the organs moist and reduce the risk of tissue damage until surgical repair can be done.

Choice D reason: Elevating the head of the client’s bed 20° may be part of the overall care plan, but it is not the immediate priority when dealing with protruding organs from an open abdominal incision.

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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

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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