Health Promotion and Maintenance
64. An infant is brought to an emergency department with a chief complaint of nausea and vomiting. Which nursing assessment finding should indicate to a nurse that the infant's dehydration is severe?
Health Promotion and Maintenance
64. An infant is brought to an emergency department with a chief complaint of nausea and vomiting. Which nursing assessment finding should indicate to a nurse that the infant's dehydration is severe?
. The infant is lethargic with a urinary output of less than 1 mL/kg/hr.
. The infant has weak pulses, poor skin turgor, and cool, mottled skin.
. The infant has warm skin, increased pulse, and capillary refill of 2 seconds.
. The infant is irritable, with dry mucous membranes and increased respirations.
Test-Taking Tip
The stem of the question asks you to identify the most severe symptoms. It is helpful to rank the answer options from best to worst in order to identify the most severe description.
Content Area: Child Health, Gastrointestinal; Integrated Process: Nursing Process, Analysis; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems
Health Promotion and Maintenance
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Answer 1 is incorrect because, although the infant with severe dehydration may have decreased or absent urinary output, lethargy and decreased urine output alone may also be indicative of moderate dehydration. Answer 2 is correct because these symptoms describe a child with significantly diminished circulation as a result of dehydration. An infant with severe dehydration has weak to absent pulses, poor skin turgor, and cool, discolored skin. Answer 3 is incorrect because these are symptoms of an infant with mild to moderate dehydration. Answer 4 is incorrect because these are symptoms of an infant with moderate dehydration. The infant with severe dehydration may be lethargic, may have parched mucous membranes, and may experience an abnormally irregular respiratory pattern.