A nurse is caring for a 6-month-old infant who has gastroenteritis. Which of the following findings should the nurse identify as a manifestation of severe dehydration?
Produces tears when crying
Sunken anterior fontanel
Weight loss of 5%
Capillary refill time 3 seconds
The Correct Answer is B
Choice A reason: Producing tears when crying is not typically a sign of severe dehydration. In fact, the ability to produce tears may suggest that the infant is not severely dehydrated.
Choice B reason: A sunken anterior fontanel is a classic sign of severe dehydration in infants. The fontanel, which is the soft spot on the top of a baby's head, can appear sunken when there is significant fluid loss.
Choice C reason: While weight loss can be a sign of dehydration, a 5% weight loss alone does not necessarily indicate severe dehydration. Other clinical signs should also be considered.
Choice D reason: A capillary refill time of 3 seconds is at the upper limit of normal. Prolonged capillary refill time can be a sign of dehydration, but it is not as specific as a sunken anterior fontanel for severe dehydration.
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Related Questions
Correct Answer is A
Explanation
Choice A reason: Hyperpyrexia, or extremely high fever, is a common symptom of acetylsalicylic acid (aspirin) poisoning. The body's response to the toxic levels of aspirin can lead to an elevated temperature as part of a systemic inflammatory response.
Choice B reason: Jaundice is not a typical symptom of acute acetylsalicylic acid poisoning. It is more commonly associated with liver conditions that cause an increase in bilirubin levels.
Choice C reason: Neck vein distention is not a common finding in acetylsalicylic acid poisoning. It is often seen in conditions that cause increased pressure in the venous system, such as heart failure.
Choice D reason: Polyuria, or excessive urination, is not a direct symptom of acetylsalicylic acid poisoning. While changes in urination can occur due to renal involvement, hyperpyrexia is a more immediate concern.
Correct Answer is A
Explanation
Choice A reason: Clearing the area of hard objects is crucial to prevent injury during a seizure. It helps to ensure that the child does not hit or get hurt by any objects in the vicinity while experiencing convulsions.
Choice B reason: Minimizing movement of the limbs is not recommended as it can cause injury to the child. Instead, the child should be allowed to move freely without restraint to avoid causing harm to their joints or muscles.
Choice C reason: Inserting a tongue blade between the teeth is an outdated and dangerous practice. It can cause injury to the child's mouth or teeth and may lead to choking if the tongue blade breaks.
Choice D reason: Placing the child in a prone position is not advised as it can obstruct the airway. The child should be placed on their side in the recovery position to keep the airway clear and allow fluids to drain from the mouth.
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