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.
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View Related questions
Correct Answer is D
Explanation
Choice A rationale
Encouraging progressive activity is generally beneficial for children with various health conditions, but it is not the primary focus for a child with polycythemia caused by a congenital heart disorder. The main concern is managing the increased blood viscosity and preventing complications related to it.
Choice B rationale
Expecting the skin to turn yellow is not a typical symptom of polycythemia. Jaundice is more commonly associated with liver conditions or hemolytic diseases, not polycythemia caused by congenital heart disorders.
Choice C rationale
Preparing for seizures is not directly related to polycythemia. Seizures are more commonly associated with neurological conditions or severe electrolyte imbalances, not polycythemia.
Choice D rationale
Preventing dehydration is crucial for children with polycythemia because dehydration can increase blood viscosity, leading to a higher risk of thrombotic events. Ensuring adequate hydration helps maintain proper blood flow and reduces the risk of complications.
Correct Answer is A
Explanation
Choice A rationale
Obtaining an influenza vaccine annually is crucial for individuals with type 1 diabetes mellitus. People with diabetes are at a higher risk of complications from infections, including influenza. The flu can lead to elevated blood sugar levels and potentially worsen diabetes control.
Therefore, getting the flu vaccine can help prevent or reduce the severity of the flu and its complications.
Choice B rationale
Administering glucagon is used for severe hypoglycemia, not hyperglycemia. Glucagon is a hormone that raises blood glucose levels by stimulating the liver to release stored glucose. It is typically used in emergency situations when a person with diabetes has very low blood sugar and is unable to consume sugar orally.
Choice C rationale
Insulin should be injected into subcutaneous tissue, not the deltoid muscle. The preferred injection sites for insulin are areas with more subcutaneous fat, such as the abdomen, thighs, buttocks, and upper arms. Injecting insulin into muscle tissue can lead to faster absorption and unpredictable blood glucose levels.
Choice D rationale
Glyburide is an oral medication used to treat type 2 diabetes, not type 1 diabetes. Type 1 diabetes requires insulin therapy because the body does not produce insulin. Glyburide works by stimulating the pancreas to release more insulin, which is not effective for individuals with type 1 diabetes who have little to no insulin production.