A 3-month-old is admitted with severe diarrhea. Yesterday, the infant weighed 11 pounds (5 kg). Today, this infant weighs 9 pounds, 8 ounces (4.3 kg). Based on this information the nurse documents that the infant has:
Severe dehydration.
Risk for fluid volume deficit.
Failure to thrive.
Malabsorption syndrome
The Correct Answer is A
A. A weight loss of 10% or more in infants within a short period is indicative of severe dehydration. The significant weight loss from 5 kg to 4.3 kg confirms this diagnosis.
B. The risk for fluid volume deficit would be noted if there were signs of potential dehydration, but in this case, the infant has already lost a significant amount of weight, confirming severe dehydration.
C. Failure to thrive is a diagnosis related to insufficient weight gain over time, rather than acute weight loss due to dehydration.
D. Malabsorption syndrome could contribute to chronic weight loss, but the acute loss in this case is more likely due to dehydration from diarrhea.
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Related Questions
Correct Answer is D
Explanation
A. Collecting all urine may be relevant in certain conditions, such as kidney function monitoring, but it is not specific to Wilms' tumor management.
B. Restrictions on venipuncture or blood pressure in a specific arm are relevant for conditions like lymphedema or post-mastectomy, not Wilms' tumor.
C. Contact precautions are necessary for infectious diseases, not applicable to Wilms' tumor.
D. Wilms' tumor is a renal tumor, and palpating the abdomen could potentially cause the tumor to rupture and spread malignant cells. Therefore, it is critical to avoid any abdominal palpation in these patients.
Correct Answer is B
Explanation
A. Obtaining a blood culture is important but is not the immediate priority when a transfusion reaction is occurring.
B. Stopping the transfusion is the first step in managing a transfusion reaction to prevent further exposure to the allergen or irritant causing the symptoms.
C. Slowing the transfusion rate might not be sufficient if a reaction is occurring; stopping it is crucial.
D. Providing a diuretic is not relevant to the management of an acute transfusion reaction.
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