A nurse is assessing a 9-month-old infant who has gastroenteritis. Which of the following findings should the nurse identify as a manifestation of severe fluid volume deficit?
Flat anterior fontanel
Dry, hot skin
Loss of 5% of weight
Absence of tears when crying
The Correct Answer is D
A. "Flat anterior fontanel." A sunken anterior fontanel, not flat, is a sign of severe dehydration in infants.
B. "Dry, hot skin." Dry skin is a symptom of dehydration, but "hot" skin may indicate fever rather than severe dehydration.
C. "Loss of 5% of weight." A 5% weight loss indicates mild dehydration; severe dehydration is characterized by a weight loss of 10% or more.
D. "Absence of tears when crying." Absence of tears is a reliable indicator of severe dehydration in infants.
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Related Questions
Correct Answer is A
Explanation
A. The child's BMI: Children with cystic fibrosis often have difficulty absorbing nutrients due to pancreatic insufficiency. Monitoring the child's BMI provides a good overall indicator of nutritional status, as it accounts for both weight and height.
B. The child's pancreatic enzyme dose: While important, the enzyme dose is adjusted to help the child digest food, but it does not directly assess nutritional status.
C. The child's diet: The diet is important, but it doesn't provide a direct, quantifiable measure of nutritional status. It's more of a management tool.
D. The child's stool analysis: Stool analysis can help assess malabsorption, but it does not directly reflect overall nutritional status in terms of growth or weight gain.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}
Explanation
1. Failure to thrive: The infant has poor weight gain despite being hungry after vomiting. Projectile vomiting, as described, often leads to insufficient caloric intake, putting the infant at risk for failure to thrive.
2. Dehydration: Repeated vomiting results in fluid loss, putting the infant at high risk of dehydration, which is common in conditions like pyloric stenosis, suspected here due to the symptoms and palpable abdominal mass.
3. Intussusception typically presents with intermittent, severe abdominal pain, "currant jelly" stools, and sometimes a sausage-shaped mass, which are not noted in this scenario.
4. Meckel diverticulum can cause painless rectal bleeding or obstruction symptoms but is not associated with projectile vomiting or a palpable mass.
5. Hirschsprung disease presents with failure to pass meconium, abdominal distension, and chronic constipation rather than the projectile vomiting seen here.
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