A nurse is caring for a toddler who has been vomiting for the past 8 hr. Which of the following findings indicates to the nurse that the child is dehydrated?

Increased blood pressure

Distended jugular veins

Flat anterior fontanel

Increased pulse

Answer and Explanation

The Correct Answer is D

A. Increased blood pressure is typically not associated with dehydration. In fact, dehydration often causes hypotension or low blood pressure, especially in severe cases.

B. Distended jugular veins are usually a sign of fluid overload or heart failure, not dehydration. In dehydration, the veins may appear flat due to decreased fluid volume.

C. A flat anterior fontanel is generally expected in a well-hydrated child. A sunken fontanel would indicate dehydration in infants and young toddlers.

D. Increased pulse (tachycardia) is a common sign of dehydration. As the body loses fluid, the heart compensates by increasing the heart rate to maintain adequate perfusion of organs.

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Correct Answer is A

Explanation

A. A 9-month-old infant is expected to demonstrate a crude pincer grasp, which involves picking up small objects between the thumb and forefinger. This is a developmental milestone for this age.

B. While infants may shake their heads by this age, it is typically not used in the context of saying "no." This action is usually a sign of exploration or reaction to stimulation.

C. A 9-month-old typically does not use two-word phrases. By this age, infants are usually babbling and may say single words like "mama" or "dada."

D. A 9-month-old is not expected to build a tower of four blocks. By 12-15 months, infants may begin to stack blocks.

A. "My child has some swelling around her eyelids and mouth." B. "My child cries when I touch the area where she received the shot." C. "My child only ate 2 ounces during her last feeding." D. "My child has a temperature of 100.7 degrees Fahrenheit."

Correct Answer is A

Explanation

A. Swelling around the eyelids and mouth can indicate an allergic reaction, which could be a sign of anaphylaxis, a life-threatening condition. This requires immediate attention and intervention.

B. Crying when the injection site is touched is a common and expected response after immunization and does not suggest a serious issue.

C. A slight decrease in appetite after immunizations can be common, but it is not typically a cause for concern unless it is persistent or accompanied by other signs of illness.

D. A mild fever after immunizations is common and usually not alarming. A temperature of 100.7°F is not high enough to be a priority concern unless it is persistent or higher.

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A nurse is caring for a toddler who has been vomiting for the past 8 hr. Which of the following findings indicates to the nurse that the child is dehydrated?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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