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 B
Explanation
Choice A reason: Hemoglobin (Hgb) of 12 g/dL is within the normal range for school-age children and is not specifically indicative of nephrotic syndrome.
Choice B reason: A serum protein level of 4.2 g/dL is lower than the normal range, which is typically between 6 and 8 g/dL. This finding is consistent with nephrotic syndrome, as the condition is characterized by proteinuria and hypoalbuminemia, leading to low serum protein levels.
Choice C reason: A BUN (Blood Urea Nitrogen) level of 15 mg/dL is within the normal range for children and does not specifically indicate nephrotic syndrome. Nephrotic syndrome is characterized by protein loss, not necessarily changes in BUN levels.
Choice D reason: A serum sodium level of 144 mEq/L is within the normal range for children. While electrolyte imbalances can occur in nephrotic syndrome, this value does not specifically indicate the condition.
Correct Answer is D
Explanation
Choice A reason: Genital herpes simplex virus is a common sexually transmitted infection, but it is not nationally notifiable. It is managed with antiviral medications and patient education.
Choice B reason: Bacterial vaginosis is a condition caused by an imbalance of bacteria in the vagina and is not classified as a sexually transmitted infection. It is not nationally notifiable.
Choice C reason: Trichomoniasis is a sexually transmitted infection caused by a parasite. While it is common and treatable, it is not nationally notifiable.
Choice D reason: Gonorrhea is a sexually transmitted bacterial infection that is nationally notifiable. Public health departments track cases of gonorrhea to monitor and control outbreaks.
Choice E reason: Human papillomavirus (HPV) is the most common sexually transmitted infection and can lead to health problems like genital warts and cancers. However, it is not nationally notifiable.
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