A 2-year-old child admitted to a burn unit with second and third-degree burns is scheduled for another wound dressing change.
The child is anticipating the painful procedure and is anxious and tachycardic as the time approaches. The nurse recognizes that which of the following is likely?

Choice A rationale

Dehydration in infants can be a serious medical concern if not addressed quickly. It can be caused by various factors such as vomiting or diarrhea, or if the baby is not nursing well. The most common signs of dehydration in babies include concentrated urine that looks very dark yellow or orange, constipation, dry lips, dry mouth, dry mucous membranes, excessive sleepiness, irritability, less than six wet diapers in a 24-hour period, no interest in taking a bottle or breastfeeding, no tears when crying, paleness, sunken fontanelle (soft spot) on their head, and wrinkled skin. If the nurse observes these signs and symptoms in the infant, along

with the intake and output record from the previous 8 hours, the nurse might determine that the patient is dehydrated during the shift.

Choice B rationale

If the infant shows signs of improvement such as increased urine output, normal skin turgor, moist mucous membranes, and the infant is alert and active, then the nurse might determine that the patient is improving as anticipated. However, without specific details about the infant’s condition, it’s difficult to definitively say that this is the case.

Choice C rationale

Fluid volume excess, also known as fluid overload, occurs when the body has too much water and electrolytes. Symptoms can include swelling in the hands, feet, ankles, or abdomen, weight gain, high blood pressure, and shortness of breath. If the nurse observes these symptoms in the infant, along with the intake and output record from the previous 8 hours, the nurse might determine that the patient has fluid volume excess. However, given the information provided, this does not seem to be the most likely scenario.

Choice D rationale

If the infant’s vital signs are stable, the infant is alert and active, and there are no significant changes in the infant’s condition, the nurse might determine that the patient’s condition is stable. However, without specific details about the infant’s condition, it’s difficult to definitively say that this is the case.

Choice A rationale

An 18-month-old who has a high fever, coughs hard, and has a runny nose requires urgent care. High fever in a child can be a sign of a serious infection or other medical condition. The hard coughing could indicate a respiratory issue such as bronchitis or pneumonia, which can be serious in young children. The runny nose is another symptom of a possible respiratory infection.

Choice B rationale

A one-year-old who has a slight fever, a rash, and green secretions may not require urgent care but should still be seen by a healthcare provider. A slight fever can be a sign of a minor infection, which may resolve on its own or with over-the-counter remedies. However, a rash

and green secretions could indicate a bacterial infection, which may require antibiotic treatment.