A nurse in an urgent care clinic is caring for an infant who presents with vomiting, diarrhea, and decreased oral intake. Which of the following manifestations should the nurse expect?
Hypertension
Decreased temperature
Oliguria
Bulging anterior fontanel
The Correct Answer is C
Rationale:
A. Hypertension: Dehydration in infants typically causes hypotension, not hypertension, due to reduced circulating volume and poor perfusion as fluid loss progresses.
B. Decreased temperature: While temperature may fluctuate in dehydration, fever is more common due to infection-related fluid loss. A decreased temperature is not a consistent sign.
C. Oliguria: Decreased urine output is a key indicator of dehydration in infants. The kidneys conserve water during hypovolemia, resulting in oliguria (less than 1 mL/kg/hr).
D. Bulging anterior fontanel: A bulging fontanel usually indicates increased intracranial pressure, not dehydration. Dehydration typically causes a sunken fontanel in infants.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Fidelity: Fidelity involves loyalty, faithfulness, and keeping promises to individuals. While important in one-on-one nursing relationships, it is not the guiding principle when planning for population-wide benefit.
B. Utilitarianism: Utilitarianism is an ethical principle focused on producing the greatest good for the greatest number of people. It is most appropriate when planning community programs that aim to maximize overall health benefits.
C. Autonomy: Autonomy emphasizes respecting individual rights and decision-making. While vital in personal healthcare decisions, it does not directly guide broad community health program planning.
D. Veracity: Veracity refers to truth-telling and honesty in communication. Although essential in client interactions, it does not provide direction in choosing programs that broadly benefit the community.
Correct Answer is C
Explanation
Rationale:
A. Hypertension: Dehydration in infants typically causes hypotension, not hypertension, due to reduced circulating volume and poor perfusion as fluid loss progresses.
B. Decreased temperature: While temperature may fluctuate in dehydration, fever is more common due to infection-related fluid loss. A decreased temperature is not a consistent sign.
C. Oliguria: Decreased urine output is a key indicator of dehydration in infants. The kidneys conserve water during hypovolemia, resulting in oliguria (less than 1 mL/kg/hr).
D. Bulging anterior fontanel: A bulging fontanel usually indicates increased intracranial pressure, not dehydration. Dehydration typically causes a sunken fontanel in infants.
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