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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Obtaining written consent from the client is appropriate as adolescents are entitled to confidential care for STIs. This respects the client's autonomy and privacy.
Choice B reason: Contacting the client's parents may not be necessary unless the adolescent is under the age specified by law for independent consent. It could also breach confidentiality.
Choice C reason: Postponing the testing could delay diagnosis and treatment, which is not in the best interest of the client. Immediate testing is important for health and well-being.
Choice D reason: Requesting verbal consent from the social worker is not appropriate as the consent should come directly from the client or their legal guardian, if required.
Correct Answer is B
Explanation
Choice A reason: Emotional separation from parents is a part of the normal individuation process that occurs during adolescence, but it is not as immediate or noticeable as mood swings during early adolescence.
Choice B reason: Mood swings are common during early adolescence due to hormonal changes and the development of the child's identity. This can result in rapid and intense emotional responses to situations.
Choice C reason: Increased self-esteem is a possible outcome of successful navigation through adolescence, but it is not guaranteed and is not a characteristic that can be expected to manifest uniformly during early adolescence.
Choice D reason: A decelerating growth rate is more characteristic of late adolescence after the major growth spurts have occurred. Early adolescence is typically a time of continued growth and development.
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