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 D
Explanation
A. While some individuals may experience discomfort or irritation from spicy foods, there is no substantial evidence linking spicy food consumption directly to the development of oral cancer. It can cause symptoms like mouth ulcers or gastritis in some people but is not recognized as a significant risk factor for oral cancer.
B. Long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs) is not directly associated with an increased risk of oral cancer. In some contexts, they may even have protective effects against certain cancers due to their anti-inflammatory properties. However, chronic use can lead to other complications, such as gastrointestinal issues, rather than directly influencing oral cancer risk.
C. Cholecystitis, or inflammation of the gallbladder, is unrelated to the development of oral cancer. It primarily affects the digestive system and does not have a known link to oral malignancies. Thus, it is not considered a risk factor for oral cancer.
D. HPV, particularly certain high-risk strains, is recognized as a significant risk factor for the development of oral cancers, especially oropharyngeal cancers. HPV can lead to cellular changes that increase the likelihood of malignancy in the oral cavity.
Correct Answer is ["A","B","C"]
Explanation
A.Gloves should be worn to protect the healthcare provider from potential exposure to C. diff spores, which can be present in the client’s stool. It also prevents the spread of infection to other patients and surfaces.
B.C. diff is highly contagious, and the spores can persist on surfaces. Restricting family members from using the client's restroom helps reduce the risk of spreading the infection to others, especially in shared facilities.
C.Placing the client in a private room helps prevent the spread of C. diff to other patients, particularly in healthcare settings. This isolation is critical for controlling outbreaks of this infection.
D. This is not recommended for C. diff. While alcohol-based hand sanitizers are effective against many pathogens, they do not effectively kill C. diff spores. Handwashing with soap and water is the preferred method after caring for a C. diff patient to ensure thorough removal of spores.
E. C. diff is primarily transmitted via the fecal-oral route, and droplet precautions are not required. Masks are typically used for respiratory infections, not for gastrointestinal infections like C. diff.
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