An infant is brought to the emergency department with poor skin turgor, weight loss, lethargy, and tachycardia. This is suggestive of:
a. Overhydration. c. Sodium excess.
b. Dehydration. d. Calcium excess.
ANS: B
These clinical manifestations indicate dehydration. Symptoms of overhydration are edema and weight gain. Regardless of extracellular sodium levels, total body sodium is usually depleted in dehydration. Symptoms of hypocalcemia are a result of neuromuscular irritability and manifest as jitteriness, tetany, tremors, and muscle twitching.
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The nurse assesses a client's Glasgow Coma Scale (GCS) score and determines it to be 12 (a 4 in each category). What care should the nurse anticipate for this client?
a. Can ambulate independently b. May have trouble swallowing c. Needs frequent re-orientation d. Will need near-total care
When signing an informed consent form, the nurse understands that her signature:
a. Indicates witness that patient signed the form. b. Confirms that the patient understands the information provided. c. Confirms that the patient is agreeing voluntarily. d. Indicates witness that the patient is of legal age.
Enemas are ordered to empty the bowel preoperatively for a child with Hirschsprung disease. The enema solution should be:
a. tap water. b. normal saline. c. oil retention. d. phosphate preparation.
The nurse should instruct the female client who has experienced two urinary tract infections within the past year to:
A) void following sexual intercourse. B) use shower gels and bubble bath. C) avoid drinking cranberry juice. D) apply powder to the perineum.