A nurse in a clinic is assessing an infant who has diarrhea, is lethargic, and has dry skin. Which of the following findings indicates moderate dehydration?
Decreased respiratory rate
Bulging anterior fontanel
Mottled skin
Capillary refill 3 seconds
The Correct Answer is D
A. "Decreased respiratory rate." Moderate dehydration typically causes tachypnea (increased respiratory rate), not a decreased respiratory rate. This is the body's response to metabolic acidosis caused by fluid loss.
B. "Bulging anterior fontanel." A bulging anterior fontanel is a sign of increased intracranial pressure, not dehydration. Dehydration typically causes a sunken fontanel due to fluid loss.
C. "Mottled skin." Mottled skin can be a sign of severe dehydration or shock, but it is not a definitive indicator of moderate dehydration.
D. "Capillary refill 3 seconds." A capillary refill time of 2–3 seconds is indicative of moderate dehydration. In severe dehydration, capillary refill would be greater than 4 seconds.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "You will need to give your child a course of corticosteroids." Corticosteroids are not used to treat scabies. Treatment involves topical permethrin cream or oral ivermectin, not steroids.
B. "Your entire home will need to be thoroughly cleaned." While cleaning bedding, clothing, and personal items is important, a full deep-cleaning of the home is not necessary because mites do not survive long away from human skin.
C. "Any person who has been in close contact with the child needs treatment." Scabies is highly contagious, and all household members and close contacts should be treated simultaneously to prevent reinfestation.
D. "Place your nonwashable items in sealed plastic bags for up to 5 days." Scabies mites can survive off the body for up to 3 days, so items should be bagged for at least 3 days, not 5.
Correct Answer is D
Explanation
A. "Encourage the adolescent to wait to ask questions about the device until after its insertion." The adolescent should be encouraged to ask questions before the procedure to ensure informed consent and understanding.
B. "Call the adolescent's guardian to obtain verbal consent prior to the procedure." In many areas, adolescents can provide consent for reproductive health services, including contraception, without parental consent.
C. "Reschedule the procedure until the client's guardian provides written consent." Most states and healthcare policies allow minors to consent to birth control procedures without requiring parental involvement.
D. "Witness the adolescent's signature on the consent form." The nurse should witness and document the adolescent’s informed consent, as they have the right to make decisions regarding their reproductive health.
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