A nurse is collecting data from an infant who has severe dehydration. Which of the following findings should the nurse expect?
Slow respirations
Capillary refill 3 seconds
Sunken fontanels
Increased blood pressure
The Correct Answer is C
A. Slow respirations:
Infants with dehydration often have tachypnea, not slow respirations.
B. Capillary refill 3 seconds:
A refill time greater than 2 seconds can be abnormal, but 3 seconds is borderline and not specific to severe dehydration.
C. Sunken fontanels:
Sunken anterior fontanel is a key sign of severe dehydration in infants due to fluid volume loss.
D. Increased blood pressure:
Blood pressure is usually low or normal in severe dehydration; hypotension may indicate shock.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "You are allowed to consult an attorney if you desire to do so."
Clients admitted for psychiatric treatment maintain the right to legal counsel and to make decisions regarding their care.
B. "You may not retract consent for procedures after signing an informed consent form."
Clients may withdraw consent at any time, even after signing the form.
C. "You may not refuse to take prescribed medications."
Clients have the right to refuse medications unless they are legally mandated or in an emergency situation.
D. "You are required to participate in scheduled group therapy sessions each day."
Clients can refuse treatments or therapies unless under legal obligation.
Correct Answer is ["A","D","E"]
Explanation
A. Flight of ideas
Rapid shifting from one topic to another is common in mania.
B. Anhedonia
Anhedonia (lack of pleasure) is a symptom of depression, not mania.
C. Overeating
While some clients may eat excessively, decreased appetite is more common in manic states.
D. Grandiose thinking
Exaggerated sense of importance and ability is typical in mania.
E. Distractibility
Inability to concentrate and getting easily distracted is common in manic episodes.
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