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 D
Explanation
Rationale:
A. Sweating is more commonly associated with hypoglycemia (low blood sugar) rather than hyperglycemia (high blood sugar).
B. Tremors are more commonly associated with hypoglycemia.
C. Pallor is not typically associated with hyperglycemia.
D. Thirst (polydipsia) is a classic symptom of hyperglycemia in diabetes mellitus, as the body tries to dilute the excess sugar in the bloodstream by increasing fluid intake.
Correct Answer is A
Explanation
Rationale:
A. Allowing the child to sit on the parent's lap can provide comfort and support during the procedure.
B. While the electrocardiogram (ECG) machine may have alarms, they are not typically related to abnormal heart rhythms during the procedure.
C. ECG leads are typically placed on the chest, not the back.
D. The duration of an ECG is relatively short, usually only a few minutes, so stating that it will take at least 30 minutes may cause unnecessary concern for the parent.
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