the nurse suspects fluid overload in an infant receiving intravenous fluids what clinical manifestation is suggestive of water intoxication
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ATI RN

RN Nursing Care of Children Online Practice 2019 A

1. The nurse suspects fluid overload in an infant receiving intravenous fluids. What clinical manifestation is suggestive of water intoxication?

Correct answer: C

Rationale: Water intoxication can lead to cerebral edema, causing neurological symptoms such as irritability and seizures. Oliguria, weight loss, and muscle weakness are not typical signs of water intoxication.

2. An infant is suspected of having esophageal atresia/tracheoesophageal fistula. While waiting for the pediatrician to see the infant, which action should the nurse take?

Correct answer: A

Rationale: Positioning the infant with the head of the bed elevated helps to prevent aspiration and manage secretions until further treatment can be provided. Choice B is incorrect as the priority is ensuring the infant's safety and health, not immediate bonding. Choice C is incorrect as breastfeeding may worsen the condition. Choice D is incorrect as it does not address the potential risk of aspiration associated with esophageal atresia/tracheoesophageal fistula.

3. What physiologic state(s) produces the clinical manifestations of nervous system stimulation and excitement, such as overexcitability, nervousness, and tetany?

Correct answer: D

Rationale: Both metabolic and respiratory alkalosis can cause overexcitability and nervous system stimulation due to a decrease in ionized calcium levels, which can cause symptoms such as tetany and paresthesias. Acidosis typically has the opposite effect, leading to depression of the nervous system.

4. The nurse notes that a child has lost 3.6 kg (8 lb) after 4 days of hospitalization for acute glomerulonephritis. What is the most likely cause of this weight loss?

Correct answer: B

Rationale: The weight loss is most likely due to the reduction of edema, as glomerulonephritis often causes fluid retention that resolves with treatment, leading to significant weight loss.

5. Which clinical manifestations should the nurse anticipate when assessing a child for hypoglycemia?

Correct answer: D

Rationale: The correct answer is D: 'Shaky feeling and dizziness.' Hypoglycemia in children often presents with symptoms like shakiness, dizziness, sweating, hunger, and irritability. These symptoms occur because the brain and body are deprived of the glucose they need to function properly. Choices A, B, and C are incorrect because lethargy, thirst, nausea, and vomiting are not typically primary manifestations of hypoglycemia in children.

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