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 D
Explanation
A. Insert an oral airway for the child. Inserting an oral airway during a tonic-clonic seizure is not recommended, as it could cause injury to the child or block the airway. During a seizure, the priority is ensuring safety rather than trying to insert devices.
B. Apply soft restraints to the child's wrists. Restraints are not recommended during a seizure, as they can increase the risk of injury. Instead, the focus should be on protecting the child from injury and allowing the seizure to run its course.
C. Place a pillow under the child's knees. While positioning the child is important, placing a pillow under the knees is not a recommended action. The goal is to move the child to the floor to prevent falls or injury during the seizure.
D. Move the child to the floor. If a child is in a wheelchair and begins to have a seizure, moving them to the floor is the first step to prevent injury. Once the child is on the floor, ensure they are on their side to allow for airway clearance and reduce the risk of aspiration.
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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