A 1-month old infant is admitted to the emergency room with severe diarrhea. Which of the following assessments suggests the infant is severely dehydrated?
High specific gravity of urine, moist mucous membranes
Low specific gravity of urine, skin color pale
Fontanelles depressed: capillary refill greater than 4 seconds
Skin moist and flushed, mucous membranes moist
The Correct Answer is C
A. A high specific gravity of urine typically indicates concentrated urine, which can occur in dehydration; however, moist mucous membranes suggest adequate hydration. This combination does not indicate severe dehydration.
B. A low specific gravity of urine usually indicates dilute urine, which is not typical in dehydration; it suggests the kidneys are not concentrating urine due to good fluid intake or other factors. While pale skin can indicate poor perfusion, this option does not specifically indicate severe dehydration.
C. A depressed fontanelle (soft spot on the head) and a capillary refill time greater than 4 seconds are significant indicators of severe dehydration in infants. Depressed fontanelles suggest that the infant is not receiving enough fluids, and prolonged capillary refill time indicates poor perfusion and dehydration.
D. Moist skin and mucous membranes indicate adequate hydration. Flushed skin may occur with certain conditions but does not suggest severe dehydration. This option reflects a well-hydrated status rather than dehydration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Distended neck veins are typically associated with conditions that lead to increased central venous pressure, such as heart failure or fluid overload, not pyloric stenosis. Therefore, this option is not relevant to pyloric stenosis.
B. Projectile vomiting is a classic symptom of pyloric stenosis. This occurs due to the obstruction caused by the thickened pylorus, which prevents food from passing into the duodenum. The vomiting is forceful and occurs shortly after feeding, making this option a hallmark of the condition.
C. A ridged (or rigid) abdomen can indicate underlying issues, such as peritonitis or other abdominal emergencies, but it is not a typical finding associated specifically with pyloric stenosis. Pyloric stenosis may lead to some degree of abdominal distension, but not necessarily to a ridged abdomen.
D. Red currant jelly stools are associated with intussusception, not pyloric stenosis. This type of stool appears when there is a mix of blood and mucus due to bowel obstruction or ischemia, but it is not a symptom of pyloric stenosis.
Correct Answer is C
Explanation
A. While emotional stress can impact overall health and potentially weaken the immune system, it is not directly related to the transmission or risk factors for salmonellosis. This information is less relevant in identifying the cause of the gastrointestinal symptoms.
B. Smoking can affect general health and immune function, but it is not specifically related to salmonellosis. While it may be a contributing factor to the client's overall health status, it doesn’t provide direct insights into potential sources of infection or recent exposures.
C. Salmonellosis is often linked to foodborne sources, particularly undercooked or contaminated foods. Knowing what the client has eaten can help identify potential sources of the infection and assist in managing the condition effectively. It can also guide public health reporting if a particular food source is identified as a risk.
D. A history of colon cancer could affect the client’s gastrointestinal health, but it is not directly relevant to the diagnosis of salmonellosis. While it may be useful to know for the overall health context, it does not help in identifying the source or confirming the diagnosis of salmonellosis.
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