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 C
Explanation
Rationale:
A. Missing front deciduous teeth are a common occurrence during childhood and are not necessarily indicative of physical abuse.
B. Weight in the 45th percentile is within the normal range for a 7-year-old and does not indicate physical abuse.
C. Bruising around the wrists can be a sign of physical abuse, especially if it appears in patterns consistent with being restrained.
D. Abrasions on the knees are common in children who are active and are not necessarily indicative of physical abuse.
Correct Answer is D
Explanation
Rationale:
A. Scaly lesions on the inner thighs are not typically characteristic of scabies. Scabies lesions are often burrow-like and appear as small, raised, grayish-white or skin- colored lines, not scaly.
B. A rash with red macular lesions on the scalp is not characteristic of scabies.
Scabies lesions typically occur in areas with thin skin, such as the webs of fingers, wrists, elbows, axillary folds, waistline, buttocks, and genitalia.
C. A bull's eye edematous area on the groin is not characteristic of scabies. Scabies lesions usually present as small, raised, grayish-white or skin-colored lines or bumps, not as bull's eye patterns.
D. Maculopapular skin burrows on the hand are a classic manifestation of scabies.
Scabies mites burrow into the skin to lay eggs, causing raised, linear, erythematous, and excoriated lesions, which may appear as small papules or vesicles with a surrounding erythematous flare.
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