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
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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Related Questions
Correct Answer is D
Explanation
A. "Chill the medication prior to administration." The medication should be warmed to room temperature to prevent discomfort or dizziness during administration.
B. "Pull the pinna up and back during medication administration." For infants, the pinna should be pulled down and back to straighten the ear canal.
C. "Hyperextend the infant's neck during medication administration." Hyperextending the neck is unnecessary and may cause discomfort; a neutral position is sufficient.
D. "Massage the anterior area of the ear following administration." Massaging the tragus helps ensure the medication is evenly distributed into the ear canal.
Correct Answer is C
Explanation
A. Warm extremities: Typically, in heart failure, extremities can feel cold due to poor circulation and reduced cardiac output.
B. Frequent headaches: Headaches are not a typical sign of heart failure in children. Although they can occur in some cases due to increased intracranial pressure, they are not characteristic of heart failure.
C. Distended neck veins: Distended neck veins are a hallmark sign of right-sided heart failure. It occurs when the heart is unable to efficiently pump blood, leading to congestion and fluid retention, which can cause blood to back up into the veins, resulting in visible distention.
D. Weight loss: Weight gain due to fluid retention is more common in heart failure. Weight loss may occur in more advanced or chronic cases due to decreased appetite and fluid shifts, but weight gain is the expected finding in early stages.
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