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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Correct Answer is B
Explanation
Choice A rationale
Administering an oral analgesic does not aid in bronchodilation and is not effective in treating laryngotracheobronchitis (Croup)10.
Choice B rationale
Assisting with racemic epinephrine nebulizer therapy is the most effective measure in aiding bronchodilation in a child with laryngotracheobronchitis (Croup). Racemic epinephrine helps reduce airway swelling and improve breathing.
Choice C rationale
Urging the child to continue to take oral fluids is important for hydration but does not directly aid in bronchodilation.
Choice D rationale
Teaching the child to take long, slow breaths can help with breathing techniques but is not the most effective measure for bronchodilation.
Correct Answer is D
Explanation
Choice A rationale
Temper tantrums are not a type of learning disability. They are a normal part of toddler development and are a way for toddlers to express frustration and assert independence.
Choice B rationale
Leaving the room while a tantrum is happening is not recommended. It is important for parents to stay calm and present, providing a safe environment for the child. Ignoring the tantrum while staying nearby can help the child learn to self-regulate.
Choice C rationale
Psychological consults are not typically necessary for temper tantrums. Temper tantrums are a normal part of development and usually decrease as the child learns to communicate and manage emotions better.
Choice D rationale
Temper tantrums are indeed the toddler’s attempt to gain control of a situation. Toddlers often have tantrums when they are unable to express their needs or when they are frustrated by their lack of control over their environment. Understanding this can help parents respond appropriately and support their child’s emotional development.