A complete blood workup is ordered for a 5 month old with tetralogy of Fallot. Because of the infant's heart disease, the nurse would expect the report to show:

Correct Answer: B

Rationale: Tetralogy of Fallot is a congenital heart defect that affects the flow of blood through the heart. In this condition, there is decreased pulmonary blood flow leading to reduced oxygenation of the blood. To compensate for the low oxygen levels in the blood, the body may increase the production of red blood cells, resulting in polycythemia (an increased red blood cell count). This is the body's way of trying to ensure that enough oxygen is carried to the tissues despite the heart defect. Therefore, in a 5-month-old infant with tetralogy of Fallot, the nurse would expect the blood workup to show polycythemia.

Correct Answer: C

Rationale: Most infants can pull themselves to a standing position at age 9 months. Infants who are not able to pull themselves to standing by age 11 to 12 months should be further evaluated for developmental dysplasia of the hip.

Correct Answer: D

Rationale: Hyponatremic dehydration presents with marked skin turgor loss while the tongue remains moist, as fluid shifts from the extracellular to intracellular space.

Correct Answer: C

Rationale: The correct nursing intervention to prevent infection in patients with AIDS is to wear protective gear such as gown, mask, gloves, and goggles when entering the patient's room. Patients with AIDS have compromised immune systems, making them more susceptible to infections. Wearing protective gear helps prevent the transmission of pathogens from healthcare providers to the patient and vice versa. It helps minimize the risk of exposure to infectious agents and protects both the patient and the healthcare team. Prohibiting visitors with a cough (option B) may be important for preventing the spread of certain infections, but it is not the most effective measure for protecting patients with AIDS. Option A is not appropriate as it isolates the patient, which can have negative psychological effects. Option D is not specific enough and does not provide clear guidance on infection prevention measures.

Correct Answer: D

Rationale: Acute phobic hallucination is not a recognized feature of childhood psychosis.