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NurseDive Free Nursing Practice Question
A nurse is caring for a 6-month-old infant who has gastroenteritis. Which of the following findings should the nurse identify as a manifestation of severe dehydration?
A. Produces tears when crying
Producing tears when crying is not typically a sign of severe dehydration. In fact, the ability to produce tears may suggest that the infant is not severely dehydrated.
B. Sunken anterior fontanel
A sunken anterior fontanel is a classic sign of severe dehydration in infants. The fontanel, which is the soft spot on the top of a baby's head, can appear sunken when there is significant fluid loss.
C. Weight loss of 5%
While weight loss can be a sign of dehydration, a 5% weight loss alone does not necessarily indicate severe dehydration. Other clinical signs should also be considered.
D. Capillary refill time 3 seconds
A capillary refill time of 3 seconds is at the upper limit of normal. Prolonged capillary refill time can be a sign of dehydration, but it is not as specific as a sunken anterior fontanel for severe dehydration.
This question is an excerpt from Nurse Dive's nursing test bank - RN ATI Nursing Care of Children 2019 Proctored Exam. Take the full exam now
Full Explanation
Choice A reason: Producing tears when crying is not typically a sign of severe dehydration. In fact, the ability to produce tears may suggest that the infant is not severely dehydrated.
Choice B reason: A sunken anterior fontanel is a classic sign of severe dehydration in infants. The fontanel, which is the soft spot on the top of a baby's head, can appear sunken when there is significant fluid loss.
Choice C reason: While weight loss can be a sign of dehydration, a 5% weight loss alone does not necessarily indicate severe dehydration. Other clinical signs should also be considered.
Choice D reason: A capillary refill time of 3 seconds is at the upper limit of normal. Prolonged capillary refill time can be a sign of dehydration, but it is not as specific as a sunken anterior fontanel for severe dehydration.
Similar Questions
A nurse is providing discharge teaching to the parents of a school-age child following the placement of a ventriculoperitoneal shunt. The nurse should determine that the teaching was effective when the parents identify which of the following as an indicator that the shunt has been displaced?
A. Decreased urine output
Decreased urine output is not directly related to ventriculoperitoneal shunt displacement. It may indicate other issues such as dehydration or kidney problems.
B. Increased sleeping
Increased sleeping is not a specific indicator of shunt displacement. While it may be a concern if there are significant changes in the child's sleep patterns, it is not a definitive sign of this complication.
C. Hyperactive bowel sounds
Hyperactive bowel sounds are not associated with shunt displacement. They may indicate gastrointestinal issues but are not relevant to the function of a ventriculoperitoneal shunt.
D. Elevated temperature
An elevated temperature can be an indicator of shunt displacement, as it may suggest an infection or other complications related to the shunt. Parents should be aware of this sign and seek medical attention if it occurs.
Full Explanation
Choice A reason: Decreased urine output is not directly related to ventriculoperitoneal shunt displacement. It may indicate other issues such as dehydration or kidney problems.
Choice B reason: Increased sleeping is not a specific indicator of shunt displacement. While it may be a concern if there are significant changes in the child's sleep patterns, it is not a definitive sign of this complication.Choice C reason: Hyperactive bowel sounds are not associated with shunt displacement. They may indicate gastrointestinal issues but are not relevant to the function of a ventriculoperitoneal shunt.
Choice D reason: An elevated temperature can be an indicator of shunt displacement, as it may suggest an infection or other complications related to the shunt. Parents should be aware of this sign and seek medical attention if it occurs.
A nurse in a community center is providing an in-service for parents about nutritional guidelines. Which of the following instructions should the nurse include in the teaching?
A. Introduce popcorn as a healthy snack at 12 months of age.
Introducing popcorn as a healthy snack at 12 months of age is not recommended due to the risk of choking. Popcorn is a choking hazard for young children and should be avoided until they are older.
B. Provide 36 oz of milk per day to a toddler.
Providing 36 oz of milk per day to a toddler may be excessive and can lead to iron deficiency anemia due to the displacement of other iron-rich foods. The American Academy of Pediatrics recommends 16-24 oz of milk per day for toddlers.
C. Offer 8 to 10 oz of juice per day to a preschooler.
Offering 8 to 10 oz of juice per day to a preschooler exceeds the American Academy of Pediatrics' recommendation of limiting juice to 4-6 oz per day for children 1-6 years old to prevent dental caries and ensure they consume more whole fruits.
D. Encourage a 15-year-old to increase calcium intake.
Encouraging a 15-year-old to increase calcium intake is appropriate as adolescence is a critical period for bone development. Adequate calcium intake supports optimal bone growth and density, helping to prevent osteoporosis later in life.
Full Explanation
Choice A reason: Introducing popcorn as a healthy snack at 12 months of age is not recommended due to the risk of choking. Popcorn is a choking hazard for young children and should be avoided until they are older.
Choice B reason: Providing 36 oz of milk per day to a toddler may be excessive and can lead to iron deficiency anemia due to the displacement of other iron-rich foods. The American Academy of Pediatrics recommends 16-24 oz of milk per day for toddlers.
Choice C reason: Offering 8 to 10 oz of juice per day to a preschooler exceeds the American Academy of Pediatrics' recommendation of limiting juice to 4-6 oz per day for children 1-6 years old to prevent dental caries and ensure they consume more whole fruits.
Choice D reason: Encouraging a 15-year-old to increase calcium intake is appropriate as adolescence is a critical period for bone development. Adequate calcium intake supports optimal bone growth and density, helping to prevent osteoporosis later in life.
A nurse is providing teaching about home care to the parent of a child who has scabies. Which of the following instructions should the nurse include in the teaching?
A. Treat everyone who came into close contact with the child.
Treating everyone who came into close contact with the child is essential because scabies is highly contagious. The mites that cause scabies can easily spread to others through direct skin contact or by sharing personal items.
B. Soak combs and brushes in boiling water for 10 minutes.
Soaking combs and brushes in boiling water for 10 minutes is a good practice to kill any mites that may be present. However, it is not the primary method of treating scabies, which requires medication.
C. Wash the child's hair with shampoo containing ketoconazole.
Washing the child's hair with shampoo containing ketoconazole is not a standard treatment for scabies. Ketoconazole is an antifungal medication, and scabies is caused by mites, not fungi.
D. Apply petroleum jelly to the affected areas.
Applying petroleum jelly to the affected areas is not an effective treatment for scabies. Scabies requires prescription medications, such as topical permethrin or oral ivermectin, to eliminate the mites.
Full Explanation
Choice A reason: Treating everyone who came into close contact with the child is essential because scabies is highly contagious. The mites that cause scabies can easily spread to others through direct skin contact or by sharing personal items.
Choice B reason: Soaking combs and brushes in boiling water for 10 minutes is a good practice to kill any mites that may be present. However, it is not the primary method of treating scabies, which requires medication.
Choice C reason: Washing the child's hair with shampoo containing ketoconazole is not a standard treatment for scabies. Ketoconazole is an antifungal medication, and scabies is caused by mites, not fungi.
Choice D reason: Applying petroleum jelly to the affected areas is not an effective treatment for scabies. Scabies requires prescription medications, such as topical permethrin or oral ivermectin, to eliminate the mites.