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 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 B
Explanation
Choice A rationale
Encouraging regular activity level as soon as possible is not appropriate for a child with streptococcal pharyngitis. Rest is important to allow the body to recover and prevent complications.
Choice B rationale
Completing the entire course of antibiotics is crucial to prevent complications such as rheumatic fever, which can result from untreated or partially treated streptococcal infections.
Choice C rationale
Expecting the lymph nodes to swell and obstruct the airway is not a typical outcome of streptococcal pharyngitis. While lymph node swelling can occur, it usually does not obstruct the airway.
Choice D rationale
Being aware that the infection may spread and cause a tooth abscess is not a common complication of streptococcal pharyngitis. The primary concern is preventing complications like rheumatic fever and ensuring complete recovery.