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?
Capillary refill time 3 seconds
Sunken anterior fontanel
Weight loss of 5%
Produces tears when crying
The Correct Answer is B
Rationale:
A. Capillary refill time of 3 seconds is within the normal range (less than 3 seconds) and does not indicate severe dehydration.
B. A sunken anterior fontanel is a significant sign of dehydration in infants and suggests severe dehydration.
C. While a weight loss of 5% can indicate dehydration, it may not necessarily represent severe dehydration. The extent of dehydration is better assessed by clinical signs such as fontanel status, skin turgor, and mucous membrane moisture.
D. Producing tears when crying is a reassuring sign and suggests adequate hydration, so it does not indicate severe dehydration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Odorless urine may be an indicator of improved hydration status but does not directly reflect the effectiveness of treatment for nephrotic syndrome.
B. Absence of pain with voiding may indicate resolution of urinary tract symptoms but is not a specific indicator of treatment effectiveness for nephrotic syndrome.
C. Increased urine output indicates improved renal function, which is a primary goal of treatment for nephrotic syndrome, making this the most appropriate indicator of treatment effectiveness.
D. Temperature within normal range is not a direct indicator of treatment effectiveness for nephrotic syndrome.
Correct Answer is C
Explanation
Rationale:
A. Dark brown blood indicates old blood and is not a sign of active bleeding.
B. Drinking through a straw can increase the risk of bleeding after tonsillectomy, so it should be avoided.
C. Frequent swallowing may indicate discomfort or bleeding and should prompt notification of the healthcare provider.
D. Clearing the throat can also increase the risk of bleeding and should be discouraged after tonsillectomy.
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