A nurse is assessing a 9-month-old infant who has gastroenteritis. Which of the following findings should the nurse identify as a manifestation of severe fluid volume deficit?

Flat anterior fontanel

Dry, hot skin

Loss of 5% of weight

Absence of tears when crying

Answer and Explanation

The Correct Answer is D

A. "Flat anterior fontanel." A sunken anterior fontanel, not flat, is a sign of severe dehydration in infants.
B. "Dry, hot skin." Dry skin is a symptom of dehydration, but "hot" skin may indicate fever rather than severe dehydration.
C. "Loss of 5% of weight." A 5% weight loss indicates mild dehydration; severe dehydration is characterized by a weight loss of 10% or more.
D. "Absence of tears when crying." Absence of tears is a reliable indicator of severe dehydration in infants.

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Correct Answer is ["B","C","D","E"]

Explanation

A. Bruises easily. Easy bruising is more commonly associated with hematologic conditions, not brain tumors.
B. Clumsiness. Clumsiness or difficulty with coordination may indicate motor function impairment caused by a brain tumor.
C. Irritability. Irritability can result from increased intracranial pressure (ICP) or other neurological changes due to a brain tumor.
D. Persistent headaches. Persistent headaches, especially those worse in the morning, are a common sign of increased ICP from a brain tumor.
E. Vomiting. Vomiting, particularly without nausea, can occur due to increased ICP.

A. Capillary refill greater than 4 seconds B. Bradycardia C. Tachypnea D. Lethargy

Correct Answer is C

Explanation

A. Capillary refill greater than 4 seconds: This indicates severe hypovolemia, not moderate.
B. Bradycardia: Bradycardia is uncommon in hypovolemia and may occur late as a sign of decompensation, especially in infants.
C. Tachypnea. Tachypnea is a compensatory response to hypovolemia as the body attempts to improve oxygenation and circulation.
D. Lethargy: While lethargy is a concerning sign, it is associated with more severe dehydration than moderate hypovolemia.

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A nurse is assessing a 9-month-old infant who has gastroenteritis. Which of the following findings should the nurse identify as a manifestation of severe fluid volume deficit?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing an initial physical examination on a child. The nurse should recognize that which of the following manifestations indicates a possible brain tumor? Select all that apply.

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