A nurse in an emergency department is caring for an infant who has a 2-day history of vomiting and an elevated temperature. Which of the following should the nurse recognize as the most reliable indicator of fluid loss?
Blood pressure.
Respiratory rate.
Body weight.
Skin integrity.
The Correct Answer is C
Choice A rationale
Blood pressure is not the most reliable indicator of fluid loss in infants. Blood pressure can remain normal until dehydration is severe.
Choice B rationale
Respiratory rate can be affected by many factors and is not the most reliable indicator of fluid loss.
Choice C rationale
Body weight is the most reliable indicator of fluid loss in infants. A significant decrease in body weight indicates significant fluid loss and helps guide appropriate fluid replacement therapy.
Choice D rationale
Skin integrity can be affected by many factors and is not the most reliable indicator of fluid loss.
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Correct Answer is ["A","B","C","D","E"]
Explanation
A. This stage occurs from birth to 18 months. Infants learn to trust their caregivers to meet their needs. If caregivers are consistent and reliable, infants develop a sense of trust.
B. This stage occurs from 18 months to 3 years. Toddlers learn to do things independently. Success leads to autonomy, while failure results in feelings of shame and doubt.
C. This stage occurs from 3 to 5 years. Children begin to assert control and power over their environment. Success leads to a sense of initiative, while failure results in guilt.
D. This stage occurs from 6 to 11 years. Children learn to cope with new social and academic demands. Success leads to a sense of competence, while failure results in feelings of inferiority.
E. This stage occurs from 12 to 18 years. Adolescents explore their independence and develop a sense of self. Success leads to a strong identity, while failure results in role confusion.
Correct Answer is D
Explanation
Choice A rationale
Developing autonomy is a normal developmental milestone for toddlers. However, the behaviors described in the question (sitting quietly, sucking thumb, turning away) are more indicative of regression rather than autonomy.
Choice B rationale
Resentment toward the mother is not a typical developmental reaction for an 18-month-old toddler. The behaviors described are more indicative of regression due to the stress of hospitalization.
Choice C rationale
Anxiety reaction can occur in toddlers who are hospitalized, but the behaviors described (sitting quietly, sucking thumb, turning away) are more indicative of regression.
Choice D rationale
Regression is a common reaction in toddlers who are hospitalized. The behaviors described (sitting quietly, sucking thumb, turning away) are typical signs of regression, where the child reverts to earlier developmental behaviors as a coping mechanism.