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 D
Explanation
Choice A rationale
Sitting on a nurse’s lap leaning forward is a position that can be used for postural drainage in infants with cystic fibrosis. This position helps drain secretions from the upper lobes of the lungs.
Choice B rationale
The supine position (lying on the back) is also used for postural drainage to target different areas of the lungs. It is not contraindicated for infants with cystic fibrosis.
Choice C rationale
Sitting on a nurse’s lap leaning backward is another position that can be used for postural drainage. This position helps drain secretions from the lower lobes of the lungs.
Choice D rationale
The Trendelenburg position (lying flat on the back with the feet elevated higher than the head) is contraindicated for infants with cystic fibrosis. This position can increase the risk of gastroesophageal reflux and aspiration, which can worsen respiratory symptoms.
Correct Answer is A
Explanation
Choice A rationale
Slightly yellow sclera, or jaundice, is a common finding in children with sickle cell anemia. The breakdown of sickled red blood cells leads to increased bilirubin levels in the blood, which can cause jaundice. This yellowing is often most noticeable in the sclera of the eyes. Jaundice is a result of hemolysis, a hallmark of sickle cell anemia, where red blood cells are destroyed faster than they can be produced.
Choice B rationale
Depigmented areas on the abdomen are not typically associated with sickle cell anemia. Sickle cell anemia primarily affects the blood and organs, leading to complications such as pain crises, anemia, and organ damage. Skin changes like depigmentation are not characteristic of this condition and may indicate other underlying issues.
Choice C rationale
Enlarged mandibular growth is not a common finding in sickle cell anemia. While children with sickle cell anemia may experience growth delays and skeletal abnormalities due to chronic anemia and bone marrow hyperactivity, mandibular enlargement is not a typical feature. Skeletal changes in sickle cell anemia are more likely to involve long bones and vertebrae.
Choice D rationale
Increased growth of long bones is not a characteristic finding in sickle cell anemia. In fact, children with sickle cell anemia may experience growth delays and shorter stature due to chronic anemia and the body’s increased demand for red blood cell production. The condition can lead to skeletal abnormalities, but these typically involve bone infarctions and deformities rather than increased growth.