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 A
Explanation
Choice A rationale
Projectile vomiting is a hallmark symptom of pyloric stenosis. It occurs due to the obstruction at the pylorus, causing forceful expulsion of stomach contents. This symptom typically appears in infants between 3 to 6 weeks of age.
Choice B rationale
A rigid abdomen is not a typical symptom of pyloric stenosis. It may indicate other abdominal issues, such as peritonitis or bowel obstruction.
Choice C rationale
Red currant jelly stools are associated with intussusception, not pyloric stenosis. Intussusception involves the telescoping of one part of the intestine into another, leading to bowel obstruction and characteristic stool appearance.
Choice D rationale
Distended neck veins are not related to pyloric stenosis. This symptom is more commonly associated with cardiac conditions or severe respiratory distress.
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale
Restraining the client during a seizure is not recommended as it can cause injury. The focus should be on ensuring the client’s safety and preventing harm.
Choice B rationale
Assessing the client’s airway patency is crucial during a seizure to ensure that the client is breathing properly and that the airway is not obstructed.
Choice C rationale
Removing objects from the client’s bed helps prevent injury during a seizure. Objects in the bed can pose a risk of harm if the client hits them during the seizure.
Choice D rationale
Placing the client in a side-lying position helps maintain an open airway and reduces the risk of aspiration. This position allows any secretions to drain out of the mouth, preventing choking.
Choice E rationale
Placing a tongue depressor in the client’s mouth is not recommended and can cause injury. It is a common misconception that this prevents the client from swallowing their tongue, but it can actually cause more harm.