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 A
Explanation
Choice A reason: Irregular bluish pigmentation on the sacral area could indicate a Mongolian spot, which is common and usually harmless, but it could also suggest other conditions that may require further evaluation. Reporting this finding is important for proper assessment and documentation.
Choice B reason: Slow, rhythmic movements of the lower extremities are normal in newborns and are known as primitive reflexes. These movements are expected and do not typically require reporting unless they are absent or abnormal.
Choice C reason: An anterior fontanel size of 3 cm (1.2 in) is within the normal range for a newborn. The fontanel should be soft and flat, and changes in size or tension should be monitored over time.
Choice D reason: Enlarged breasts in newborns are also common due to maternal hormones and usually resolve without intervention. It is not a finding that typically requires immediate reporting unless there is redness, swelling, or discharge.
Correct Answer is C
Explanation
Choice A reason: Talking to a toddler about the meaning of death may not be appropriate or helpful, as they may not fully understand the concept. It's important to provide comfort rather than potentially causing confusion or distress.
Choice B reason: While encouraging friends to visit can provide social support, it may not always be feasible or in the best interest of the child's health, especially if the child is very ill or immunocompromised.
Choice C reason: Staying close to the child provides emotional support and comfort, which is crucial during this difficult time. Physical presence and affection can be very reassuring for both the child and the parents.
Choice D reason: Changing the child's schedule every day can be disruptive and may cause additional stress. Consistency and routine can provide a sense of security and stability for a child who is terminally ill.
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