A 3-month-old is admitted with severe diarrhea. Yesterday, the infant weighed 11 pounds (5 kg). Today, this infant weighs 9 pounds, 8 ounces (4.3 kg). Based on this information the nurse documents that the infant has:
Severe dehydration.
Risk for fluid volume deficit.
Failure to thrive.
Malabsorption syndrome
The Correct Answer is A
A. A weight loss of 10% or more in infants within a short period is indicative of severe dehydration. The significant weight loss from 5 kg to 4.3 kg confirms this diagnosis.
B. The risk for fluid volume deficit would be noted if there were signs of potential dehydration, but in this case, the infant has already lost a significant amount of weight, confirming severe dehydration.
C. Failure to thrive is a diagnosis related to insufficient weight gain over time, rather than acute weight loss due to dehydration.
D. Malabsorption syndrome could contribute to chronic weight loss, but the acute loss in this case is more likely due to dehydration from diarrhea.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Contact precautions are used for infections that spread through direct or indirect contact with contaminated surfaces or items, which is not the case for measles.
B. Droplet precautions are used for infections spread through large respiratory droplets, such as influenza, but measles requires different precautions.
C. Protective environment precautions are used for immunocompromised patients to prevent infections but are not specific to measles.
D. Measles is spread through airborne droplets, so airborne precautions are required to prevent the spread of the virus through the air.
Correct Answer is A
Explanation
A. Agitation can be a sign of hypoxemia, as the body responds to low oxygen levels with restlessness and anxiety.
B. Nausea is less directly related to hypoxemia and more often associated with other conditions.
C. Hypotension is not a typical primary manifestation of hypoxemia; it is more associated with severe or advanced stages of illness.
D. Dysphagia (difficulty swallowing) is not a common symptom of hypoxemia during an asthma attack.
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