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 A,B,C,D
Explanation
A. Inspection: The nurse begins with a visual examination of the abdomen, looking for any abnormalities in skin color, shape, or movement.
B. Auscultation: Next, the nurse listens to the bowel sounds using a stethoscope. This step is performed before palpation to avoid altering the bowel sounds.
C. Superficial palpation: The nurse gently presses the surface of the abdomen to assess for any tenderness, distension, or masses.
D. Deep palpation: Finally, the nurse applies deeper pressure to feel for any deeper structures or masses within the abdomen.
Correct Answer is D
Explanation
A. Seizures are not a typical complication of polycythemia, though they may occur if the condition progresses to severe levels of blood viscosity.
B. Yellowing of the skin (jaundice) is not associated with polycythemia but with liver conditions.
C. While activity is important, preventing dehydration is more critical in managing polycythemia because dehydration increases blood viscosity, exacerbating the condition.
D. Preventing dehydration is essential as it helps maintain adequate blood flow and reduces the risk of thrombotic events in a child with polycythemia.
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