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 C
Explanation
A. Rest is recommended until the child recovers, as exertion can worsen symptoms and delay healing.
B. While streptococcal infections can lead to complications, a tooth abscess is not a typical concern.
C. Completing the entire course of antibiotics is crucial to prevent complications such as rheumatic fever and glomerulonephritis.
D. Swollen lymph nodes are common, but they typically do not obstruct the airway in streptococcal pharyngitis.
Correct Answer is A
Explanation
A. Puberty might be considered delayed if there are no scrotal changes by the age of 11 years, as testicular enlargement is one of the earliest signs of puberty in boys.
B. Growth spurts typically occur early in puberty, not towards the end.
C. Changes in voice occur later in puberty, not at the beginning.
D. Gynecomastia (breast tissue development) commonly occurs during early puberty rather than late puberty and is usually temporary.
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