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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Related Questions
Correct Answer is C
Explanation
Choice A reason: Weight loss is not typically an indication of heart failure. In fact, patients with heart failure may experience weight gain due to fluid retention.
Choice B reason: Decreased respirations are not a common sign of heart failure. Instead, heart failure can cause increased respiratory rate and effort due to fluid accumulation in the lungs.
Choice C reason: Exercise intolerance, or difficulty in engaging in physical activity, is a classic symptom of heart failure. It occurs due to the heart's inability to pump enough blood to meet the body's demands during exercise.
Choice D reason: Bradycardia, or a slower than normal heart rate, is not a direct indication of heart failure. While it can be associated with certain cardiac conditions, it is not a specific sign of heart failure.
Correct Answer is C
Explanation
Choice A reason: Applying lotion to the skin under the straps is not recommended as it can interfere with the harness's grip and may lead to slippage or improper positioning.
Choice B reason: Expecting the baby to wear the harness for only 2 weeks may be incorrect as the duration of use is typically determined by the physician based on the infant's progress and may extend beyond 2 weeks.
Choice C reason: Placing the diaper under the straps is correct as it allows for easy diaper changes without removing the harness and ensures that the harness remains in the proper position.
Choice D reason: Adjusting the straps daily is not advised unless instructed by a healthcare professional. Improper adjustments can affect the effectiveness of the harness and the treatment of developmental dysplasia of the hip.
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