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?
Capillary refill time 3 seconds
Sunken anterior fontanel
Weight loss of 5%
Produces tears when crying
The Correct Answer is B
Rationale:
A. Capillary refill time of 3 seconds is within the normal range (less than 3 seconds) and does not indicate severe dehydration.
B. A sunken anterior fontanel is a significant sign of dehydration in infants and suggests severe dehydration.
C. While a weight loss of 5% can indicate dehydration, it may not necessarily represent severe dehydration. The extent of dehydration is better assessed by clinical signs such as fontanel status, skin turgor, and mucous membrane moisture.
D. Producing tears when crying is a reassuring sign and suggests adequate hydration, so it does not indicate severe dehydration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. This amount of drainage may be expected postoperatively, and it is not indicative of a significant issue.
B. This is a concerning finding indicating possible inadequate renal perfusion, especially considering the postoperative status of the toddler.
C. While slightly lower than the typical body temperature, it is not necessarily abnormal, particularly in a postoperative setting.
D. Pulses of 2+ indicate adequate perfusion and are not concerning.
Correct Answer is ["A","B","C","F","H"]
Explanation
Rationale:
A.Clients with sickle cell disease are at increased risk for infections, including those caused by pneumococcus. Ensuring vaccination status helps prevent future complications.
B. Folic acid supplementation may be part of the overall management of sickle cell disease, but it is not a priority intervention during a vaso-occlusive crisis.
C. Vaso-occlusive crises can lead to tissue hypoxia due to impaired blood flow.
Continuous monitoring of oxygen saturation helps in assessing tissue perfusion and detecting hypoxemia early.
D. Placing the client on strict bed rest can increase the risk of thrombosis and impair circulation.
E.Cold can cause vasoconstriction, worsening the pain and sickling process. Warm compresses are more appropriate for promoting comfort and improving circulation.
F. Meperidine (Demerol) is a potent opioid analgesic that can help alleviate severe pain associated with vaso-occlusive crises.
G. The nurse should not restrict oral intake, as hydration is important to prevent dehydration and further sickling.
H. Hydroxyurea is used to prevent vaso-occlusive crises in patients with sickle cell disease but is not typically administered during an acute crisis. This is a medication that reduces the frequency and severity of vaso-occlusive crises by increasing the production of fetal hemoglobin, which prevents sickling.
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