A nurse is caring for a 6-month-old infant who has gastroenteritis. Which of the following findings should the nurse identify as a manifestation of severe dehydration?
Produces tears when crying
Sunken anterior fontanel
Weight loss of 5%
Capillary refill time 3 seconds
The Correct Answer is B
Choice A reason: Producing tears when crying is not typically a sign of severe dehydration. In fact, the ability to produce tears may suggest that the infant is not severely dehydrated.
Choice B reason: A sunken anterior fontanel is a classic sign of severe dehydration in infants. The fontanel, which is the soft spot on the top of a baby's head, can appear sunken when there is significant fluid loss.
Choice C reason: While weight loss can be a sign of dehydration, a 5% weight loss alone does not necessarily indicate severe dehydration. Other clinical signs should also be considered.
Choice D reason: A capillary refill time of 3 seconds is at the upper limit of normal. Prolonged capillary refill time can be a sign of dehydration, but it is not as specific as a sunken anterior fontanel for severe dehydration.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: The concrete operational phase typically begins around age 7 and is characterized by the development of logical thought about concrete events. This phase is not typical for preschoolers, who are usually between the ages of 3 and 5.
Choice B reason: The formal operational phase usually starts at age 11 or older. It involves abstract thinking and the ability to systematically plan for the future, which is beyond the cognitive abilities of a preschooler.
Choice C reason: The preoperational phase occurs from ages 2 to 7. During this stage, children begin to engage in symbolic play and learn to manipulate symbols, but they do not yet understand concrete logic.
Choice D reason: The sensorimotor phase is from birth to about age 2. During this stage, infants learn about the world through their senses and actions, such as looking and touching. Preschoolers have typically moved beyond this phase.
Correct Answer is A
Explanation
Choice A reason: A creatinine level of 1.4 mg/dL is higher than the normal range for a 4-year-old child and could indicate kidney impairment, which is a concern when administering gentamicin due to its potential nephrotoxic effects. The provider should be informed immediately to assess kidney function and adjust the medication if necessary.
Choice B reason: A BUN level of 6 mg/dL is within the normal range for children and does not typically warrant immediate concern. However, it should be monitored along with creatinine levels to assess kidney function.
Choice C reason: A creatinine level of 0.3 mg/dL is within the normal range for a 4-year-old child and does not indicate an immediate concern. It should be monitored for any changes, especially when on gentamicin.
Choice D reason: A BUN level of 12 mg/dL is slightly elevated but may not be immediately concerning. It should be evaluated in conjunction with other laboratory values and clinical findings.
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