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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Emotional separation from parents is a part of the normal individuation process that occurs during adolescence, but it is not as immediate or noticeable as mood swings during early adolescence.
Choice B reason: Mood swings are common during early adolescence due to hormonal changes and the development of the child's identity. This can result in rapid and intense emotional responses to situations.
Choice C reason: Increased self-esteem is a possible outcome of successful navigation through adolescence, but it is not guaranteed and is not a characteristic that can be expected to manifest uniformly during early adolescence.
Choice D reason: A decelerating growth rate is more characteristic of late adolescence after the major growth spurts have occurred. Early adolescence is typically a time of continued growth and development.
Correct Answer is B
Explanation
Choice A reason: Asking the parent to leave the room during the injections is not recommended as the presence of a parent can provide comfort to the infant, which may help in reducing pain and anxiety.
Choice B reason: Administering the injections while the infant is breastfeeding is an effective method to decrease pain. Breastfeeding provides comfort and distraction, and the natural sugars in breast milk can have a mild analgesic effect.
Choice C reason: Applying a warm pack to the injection site prior to administration is not a standard practice for reducing pain from immunizations. Instead, using a cold compress after the injection can help to reduce swelling and discomfort.
Choice D reason: Administering injections in the deltoid muscle is not appropriate for a 2-month-old infant due to the underdeveloped muscle mass. The anterolateral thigh is the recommended site for immunizations in infants.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.