Difficulty: Medium
Average Score: 90%
Simulated
Passage / Scenario
A nurse in a clinic is assessing an infant who has diarrhea, is lethargic, and has dry skin.Which of the following findings indicates moderate dehydration?
Correct answer
D
Rationale
The correct answer is D: Capillary refill 3 seconds. In moderate dehydration, decreased circulating blood volume leads to delayed capillary refill time. This occurs because of reduced blood flow to the peripheries. A capillary refill time of 3 seconds indicates moderate dehydration.
Choice A (Decreased respiratory rate) is incorrect as it is more commonly associated with severe dehydration.
Choice B (Bulging anterior fontanel) is a sign of increased intracranial pressure, which is seen in severe dehydration.
Choice C (Mottled skin) is typically seen in shock or severe dehydration, not moderate dehydration.
In summary, the other choices are incorrect because they represent more severe signs of dehydration compared to the delayed capillary refill time of 3 seconds, which is indicative of moderate dehydration.
Choice A (Decreased respiratory rate) is incorrect as it is more commonly associated with severe dehydration.
Choice B (Bulging anterior fontanel) is a sign of increased intracranial pressure, which is seen in severe dehydration.
Choice C (Mottled skin) is typically seen in shock or severe dehydration, not moderate dehydration.
In summary, the other choices are incorrect because they represent more severe signs of dehydration compared to the delayed capillary refill time of 3 seconds, which is indicative of moderate dehydration.