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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "I will cook foods that are low in fat and carbohydrates.": Children with cystic fibrosis often require a high-calorie, high-fat diet to meet their increased energy needs.
B. "My child can chew their enzyme medication with meals.": Enzyme medications should not be chewed as they can irritate the oral mucosa; they should be swallowed whole or sprinkled on soft food.
C. "I will give my child stool softeners for constipation." Constipation is a common issue in cystic fibrosis due to thickened intestinal secretions. Stool softeners help prevent this complication.
D. "My child will be excused from physical education class.": Physical activity is encouraged for children with cystic fibrosis to improve lung function.
Correct Answer is D
Explanation
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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