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
Droplet precautions are used for infections spread through large respiratory droplets, such as influenza, but are not sufficient for measles.
Choice B rationale
Airborne precautions are necessary for measles, as it is spread through small droplets that can remain suspended in the air and travel over long distances.
Choice C rationale
Contact precautions are used for infections spread through direct contact with the patient or their environment, such as MRSA, but are not sufficient for measles.
Choice D rationale
A protective environment is used for patients with compromised immune systems to protect them from infections, not for preventing the spread of infections like measles.
Correct Answer is D
Explanation
Choice A rationale
The influenza vaccine is recommended annually for all individuals, including adolescents, to protect against the flu. However, it is not specifically required for pre-college physical assessments.
Choice B rationale
The pneumococcal polysaccharide vaccine is typically administered to older adults and individuals with certain medical conditions. It is not a standard requirement for adolescents.
Choice C rationale
The Bacille Calmette-Guérin (BCG) vaccine is used in countries with a high prevalence of tuberculosis. It is not commonly administered in the United States or required for pre-college physical assessments.
Choice D rationale
The meningococcal polysaccharide vaccine is recommended for adolescents, especially those entering college, to protect against meningococcal disease, which can spread in close living quarters.