A 3-year-old child is admitted to a pediatric unit with moderate dehydration.
The nurse would expect to see which of the following assessment findings in this child?
Pulse of 160, oliguria, sunken fontanels, and an admission weight of 30 lbs.
Pulse of 180, furrowed tongue, mottled skin, and an admission weight of 28 lbs.
Pulse of 120, dry mucous membranes, pale, and an admission weight of 30.2 lbs.
Pulse of 150, poor skin turgor, oliguria, and an admission weight of 29.5 lbs.
The Correct Answer is D
Answer: D. Pulse of 150, poor skin turgor, oliguria, and an admission weight of 29.5 lbs. Rationale:
Choice A: A pulse of 160 is slightly elevated for a 3-year-old (normal range is 90-140 bpm), but not significantly so. Oliguria (decreased urine output) is a common sign of dehydration. However, sunken fontanels are typically seen in infants with severe
dehydration and not necessarily present in moderate cases. An admission weight of 30 lbs is irrelevant for assessing dehydration.
Choice B: A pulse of 180 is significantly elevated and suggests potential tachycardia, which can be a sign of severe dehydration or other underlying conditions. While a furrowed tongue can occur with dehydration, it's not specific enough. Mottled skin can be caused by various factors and isn't a definitive sign of moderate dehydration.
Admission weight alone isn't indicative of dehydration.
Choice C: A pulse of 120 is within the normal range for a 3-year-old. Dry mucous membranes are a common sign of dehydration. However, pale skin can be caused by various factors and isn't specific to dehydration. Admission weight alone isn't indicative of dehydration.
Choice D: A pulse of 150 is slightly elevated, potentially indicating dehydration or other factors. Poor skin turgor is a key assessment finding in moderate dehydration. It refers to the skin's slow return to its original shape after being pinched, indicating a lack of fluid. Oliguria is a common sign of dehydration, suggesting decreased fluid intake or output. An admission weight of 29.5 lbs might be slightly lower than the child's baseline weight due to dehydration, but weight alone shouldn't be used to diagnose dehydration.
Therefore, considering the combination of a slightly elevated pulse, poor skin turgor, oliguria, and a potential decrease in weight, choice D presents the most likely assessment findings in a child with moderate dehydration.
It's important to remember that a comprehensive assessment, including history, physical examination, and potentially laboratory tests, is crucial for diagnosing and classifying the severity of dehydration in children.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Distracting the patient and then taking the blanket for washing might seem like a practical solution, but it can lead to trust issues. The patient may feel betrayed or tricked, which can negatively affect the therapeutic relationship between the nurse and the patient.
Choice B rationale
Acknowledging that the blanket seems to be his favorite and allowing him to keep it with him is the best course of action. The blanket likely provides comfort and security to the patient.
Taking it away, even temporarily, can cause distress. The nurse should respect the patient’s attachment to the blanket and look for alternative solutions for maintaining hygiene, such as offering to clean the blanket when the patient is ready to part with it temporarily.
Choice C rationale
Telling the patient that you want to take the blanket home to wash and that you will bring it back might not be reassuring enough for the patient. The patient may worry about the blanket getting lost or not returned, which can cause unnecessary anxiety.
Choice D rationale
Suggesting getting him another blanket so that he will not mind giving up the current one might not work. The patient’s attachment is likely to the specific blanket, not to blankets in general. A new blanket will not have the same familiarity and comforting effect as the old one.
Correct Answer is ["69"]
Explanation
Step 1 is: To calculate the total body surface area (TBSA) involved in burns, we use the rule of nines or a modified version for children. For a 7-year-old child, the head accounts for 8.5% (front) + 8.5% (back), and each leg accounts for 6.5% (front) + 6.5% (back)3.
Step 2 is: Therefore, the total percentage of TBSA involved is (8.5% + 8.5%) + 2 * (6.5% + 6.5%) = 17% (head) + 26% (each leg) * 2 = 17% + 52% = 69%. So, the calculated percentage of total body surface area involved is 69%.
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