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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Pyloric stenosis causes projectile vomiting and dehydration due to gastric outlet obstruction, not inadequate motility of the intestine.
B. Hirschsprung's disease (congenital aganglionic megacolon) leads to inadequate motility of part of the intestine and results in a mechanical obstruction.
C. Encopresis refers to the involuntary defecation in children, typically related to constipation, not motility issues.
D. Enterocolitis is inflammation of the intestine and can cause symptoms such as diarrhea, but it is not characterized by inadequate motility of the intestine.
Correct Answer is A
Explanation
A. Toddlers are beginning to cooperate in simple chores and tasks, which aligns with their developmental stage.
B. Toddlers often struggle with separation anxiety and do not separate easily from their caregivers.
C. Understanding the difference between right and wrong is a skill that develops later, typically around age 4 or older.
D. Printing letters and numbers is beyond the developmental capabilities of a toddler and is expected later in early childhood.
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