A 3-month-old is admitted with severe diarrhea. Yesterday, the infant weighed 11 pounds (5 kg). Today, this infant weighs 9 pounds, 8 ounces (4.3 kg). Based on this information, the nurse documents that the infant has:
Failure to thrive.
Malabsorption syndrome.
Severe dehydration.
Risk for fluid volume deficit.
The Correct Answer is C
Choice A rationale
Failure to thrive is a condition where a child does not gain weight or grow as expected. While severe diarrhea can contribute to failure to thrive, the immediate concern in this scenario is the significant weight loss indicating severe dehydration.
Choice B rationale
Malabsorption syndrome involves the inability to absorb nutrients properly, leading to malnutrition and weight loss. However, the acute weight loss in this case is more indicative of severe dehydration.
Choice C rationale
Severe dehydration is characterized by significant fluid loss, which can be life-threatening in infants. The weight loss from 11 pounds to 9 pounds, 8 ounces indicates a substantial fluid loss, pointing to severe dehydration.
Choice D rationale
Risk for fluid volume deficit is a potential diagnosis, but the significant weight loss and clinical presentation indicate that the infant is already experiencing severe dehydration.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is D
Explanation
Choice A rationale
A low-carbohydrate, low-protein diet is not appropriate for a child with acute glomerulonephritis. Carbohydrates and proteins are essential nutrients, and restricting them can lead to malnutrition and other complications.
Choice B rationale
A regular diet with no added salt is not sufficient for managing acute glomerulonephritis with peripheral edema. Sodium restriction is necessary to help reduce fluid retention and edema.
Choice C rationale
A low-protein, low-potassium diet is not the best choice for managing acute glomerulonephritis. While protein and potassium intake may need to be monitored, the primary focus should be on sodium and fluid restriction.
Choice D rationale
A low-sodium, fluid-restricted diet is the correct choice. Sodium restriction helps reduce fluid retention and edema, while fluid restriction helps manage fluid balance and prevent further complications.
Correct Answer is C
Explanation
Choice A rationale
Over-riding suture lines are not a typical manifestation of hydrocephalus. This condition involves the accumulation of cerebrospinal fluid within the brain’s ventricles, leading to increased intracranial pressure.
Choice B rationale
A backward sloping appearance of the forehead is not associated with hydrocephalus. This condition typically presents with an enlarged head circumference due to fluid accumulation.
Choice C rationale
Dilated scalp veins are a common manifestation of hydrocephalus. The increased intracranial pressure causes the veins to become more prominent and visible.
Choice D rationale
Hypertension is not a primary symptom of hydrocephalus in newborns. The condition primarily affects the brain and skull, leading to symptoms like an enlarged head, bulging fontanelles, and dilated scalp veins.