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:

Failure to thrive.

Malabsorption syndrome.

Severe dehydration.

Risk for fluid volume deficit.

Answer and Explanation

The Correct Answer is C

The correct answer is Choice C.

Choice A rationale

Failure to thrive is a condition where a child does not gain weight or grow as expected. While severe diarrhea can contribute to failure to thrive, the immediate concern in this scenario is the significant weight loss indicating severe dehydration.

Choice B rationale

Malabsorption syndrome involves the inability to absorb nutrients properly, leading to malnutrition and weight loss. However, the acute weight loss in this case is more indicative of severe dehydration.

Choice C rationale

Severe dehydration is characterized by significant fluid loss, which can be life-threatening in infants. The weight loss from 11 pounds to 9 pounds, 8 ounces indicates a substantial fluid loss, pointing to severe dehydration.

Choice D rationale

Risk for fluid volume deficit is a potential diagnosis, but the significant weight loss and clinical presentation indicate that the infant is already experiencing severe dehydration.

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Correct Answer is B

Explanation

The correct answer is Choice B.

Choice A rationale

Reading a story every night is beneficial for cognitive and language development but does not specifically address the developmental task of autonomy versus shame and doubt, which is the focus for toddlers according to Erikson.

Choice B rationale

Allowing a toddler to pull a talking-duck toy fosters autonomy and independence, which are key aspects of Erikson’s developmental stage for toddlers. This activity encourages the child to explore and make choices independently.

Choice C rationale

Feeding the toddler his lunch does not promote autonomy. Instead, it may contribute to dependence, which is contrary to the developmental task of this age group.

Choice D rationale

Watching a puppet show on television is a passive activity that does not actively engage the child in developing autonomy or independence.

A. Do not palpate abdomen. B. No venipuncture or blood pressure in left arm. C. Collect all urine. D. Contact precautions.

Correct Answer is A

Explanation

The correct answer is Choice A.

Choice A rationale

Wilms tumor, also known as nephroblastoma, is a type of kidney cancer that primarily affects children. It is crucial not to palpate the abdomen of a child with a suspected Wilms tumor because this can cause the tumor to rupture and spread cancerous cells to other parts of the body.

Choice B rationale

This choice is incorrect because there is no specific restriction on venipuncture or blood pressure measurements in the left arm for children with Wilms tumor. This precaution is typically associated with conditions like lymphedema or after a mastectomy.

Choice C rationale

Collecting all urine is not a specific precaution for Wilms tumor. While monitoring urine output can be important in various conditions, it is not a primary concern for Wilms tumor.

Choice D rationale

Contact precautions are not necessary for Wilms tumor as it is not an infectious disease. Contact precautions are typically used for conditions that are contagious or spread through direct contact.

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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:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When the nurse examines a toddler, she suggests to his mother that the activity that could most appropriately foster his developmental task according to Erikson would be to:

Correct Answer is B

Explanation

A child is admitted with a suspected diagnosis of Wilms tumor.The nurse should place a sign with which of the following warnings over the child’s bed?

Correct Answer is A

Explanation

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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: