A 9-month-old infant with diarrhea has sunken eyes, dry mucosa, lethargy, and delayed skin turgor. The mother reports decreased urine output. What is the priority nursing concern?

1. A

   Risk for impaired skin integrity

2. B

   Fluid volume deficit

3. C

   Imbalanced nutrition

4. D

   Risk for infection

Appeared in: NORCET 8 Prelims-2025

Explanation

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• The infant's cluster of symptoms—sunken eyes, dry mucosa, lethargy, poor skin turgor, and low urine output—are definitive signs of dehydration, which is a state of fluid volume deficit.
• Fluid volume deficit is a life-threatening condition, especially in infants, as it can rapidly progress to hypovolemic shock by compromising circulatory volume.
• According to prioritization frameworks like Maslow's hierarchy or the ABCs (Airway, Breathing, Circulation), maintaining physiological stability is the top priority. Fluid volume deficit directly threatens circulation.
• Lethargy is a particularly ominous sign, suggesting that the dehydration is moderate to severe and is affecting central nervous system perfusion, requiring immediate intervention.

Why Other Options Were Wrong

• Option A: While frequent, watery stools put the infant at risk for skin breakdown in the perineal area, this is not an immediate life-threatening problem compared to systemic circulatory collapse from dehydration.
• Option C: Diarrhea certainly leads to poor nutrient absorption, but restoring fluid and electrolyte balance is the immediate priority to sustain life. Nutritional support can only be effective once the infant is hemodynamically stable.
• Option D: The underlying cause of the diarrhea is likely an infection. However, the priority nursing diagnosis must address the most immediate life-threatening consequence of the illness, which is the fluid volume deficit, not the underlying cause itself.

Related Visual

Clinical Relevance

• Nursing practice connection: Safe nursing care depends on performing Prioritization of nursing diagnoses in a pediatric patient with dehydration in the correct sequence, documenting the action clearly, and monitoring for the expected response.
• Rapid recognition and management of dehydration in infants is a critical nursing skill. Infants have a higher percentage of body water and a higher metabolic rate, making them highly susceptible to rapid deterioration from fluid loss.
• Priority nursing interventions include initiating oral rehydration therapy (ORT) for mild-moderate dehydration or preparing for intravenous (IV) fluid administration for severe cases, as ordered. Continuous monitoring of vital signs, level of consciousness, and urine output (by weighing diapers) is essential.
• What if? If the infant had diarrhea but was still playful, had moist mucous membranes, and a normal number of wet diapers, the priority nursing diagnosis would be 'Risk for fluid volume deficit'. The focus would shift to parent education on providing oral rehydration solutions (ORS) at home and signs to watch for that indicate worsening dehydration.

How to Approach the Question

• First, carefully read the clinical scenario and identify the patient population: a 9-month-old infant.
• Next, cluster the presenting signs and symptoms: diarrhea, sunken eyes, dry mucosa, lethargy, delayed skin turgor, and decreased urine output. Recognize this pattern as classic dehydration.
• Apply a prioritization framework. Ask, 'Which of these problems will kill the patient first?' Use frameworks like Maslow's Hierarchy (physiological needs first) or the ABCs (Airway, Breathing, Circulation).
• Evaluate the options in the context of this framework. Fluid volume deficit directly impacts 'Circulation' and is a fundamental physiological need.
• Systematically rule out the other options as less immediate priorities. Skin integrity, nutrition, and the underlying infection are all valid concerns but are secondary to the immediate life threat posed by severe dehydration and potential shock.

Concept Tested & Keywords

• Concept Tested: Prioritization of nursing diagnoses in a pediatric patient with dehydration.
• Stem keywords: 9-month-old infant, diarrhea, sunken eyes, dry mucosa, lethargy, delayed skin turgor, decreased urine output
• Lead-in keywords: priority nursing concern
• Clinical cues: Lethargy: Indicates moderate to severe dehydration and potential for decreased cerebral perfusion.
• Clinical cues: Delayed skin turgor: A classic sign of significant extracellular fluid loss.

Question ID

Q9VU1pPGFIGQ_3FXD4SRzq

Copy ID

Reference Book

E6 Nursing Fundamentals Potter Perry 12e Part 5 p. 63-65

E6 Ghai Essential Pediatrics(pp 26-904 of 913) p. 310-312