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 A
Explanation
Choice A rationale
Measuring head circumference every shift is unnecessary for a 6-year-old child with bacterial meningitis. This intervention is more relevant for infants where head circumference changes can indicate increased intracranial pressure.
Choice B rationale
Implementing seizure precautions is necessary as bacterial meningitis can cause seizures due to increased intracranial pressure and inflammation.
Choice C rationale
Admitting the client to a private room is necessary to prevent the spread of infection, as bacterial meningitis can be highly contagious.
Choice D rationale
Placing the client in a semi-Fowler’s position helps reduce intracranial pressure and promotes comfort.
Correct Answer is A
Explanation
Choice A rationale
The inability to stand upright without support at 15 months is a developmental delay that should be reported to the provider. By this age, most toddlers can stand and walk independently. Delays in motor skills can indicate underlying neurological or musculoskeletal issues.
Choice B rationale
Building a tower of six to seven cubes is a skill typically developed by 24 months. At 15 months, a toddler may only be able to stack two to three cubes.
Choice C rationale
Jumping with both feet is a skill that develops around 24 to 36 months. It is not expected for a 15-month-old toddler to be able to jump with both feet.
Choice D rationale
Turning a doorknob is a fine motor skill that develops around 24 to 36 months. It is not expected for a 15-month-old toddler to have this skill.