A nurse is assessing a child for dehydration.
Select all the clinical manifestations of dehydration in children mentioned in the text.
Thirst and dry mouth.
Decreased urine output and dark-colored urine.
Rapid heart rate and low blood pressure in severe cases.
Poor skin turgor.
Increased energy and playfulness.
Correct Answer : A,B,C,D
Choice A rationale:
Thirst and dry mouth are early signs of dehydration.
When the body loses fluids, it signals the brain to increase thirst and conserve water.
Dry mouth can occur due to reduced saliva production when the body is dehydrated.
Choice B rationale:
Decreased urine output and dark-colored urine are indicators of concentrated urine, suggesting dehydration.
Reduced fluid intake or excessive fluid loss can lead to decreased urine production, and the urine becomes more concentrated, appearing darker than usual.
Choice C rationale:
Rapid heart rate and low blood pressure are signs of hypovolemic shock, a severe form of dehydration where the body cannot circulate enough blood to meet its needs.
This can happen in severe cases of dehydration when there is a significant loss of fluids and electrolytes.
Choice D rationale:
Poor skin turgor is a classic clinical sign of dehydration.
Skin turgor refers to the skin's ability to return to its normal position after being pinched.
In dehydrated individuals, the skin loses elasticity and remains tented or "pinched" after being pulled up.
This indicates a lack of fluid in the body.
Choice E rationale:
Increased energy and playfulness are not typical signs of dehydration.
Dehydrated children are more likely to be lethargic and irritable due to the physiological stress on their bodies.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Normal saline (0.9% NaCl).
Rationale: Normal saline is the most appropriate choice for a client with dehydration and hyponatremia.
It provides a balanced solution with sodium and chloride, which can help correct hyponatremia and rehydrate the client.
It is an isotonic solution and is commonly used for fluid resuscitation.
Choice B rationale:
Half normal saline (0.45% NaCl).
Rationale: Half normal saline is also an isotonic solution, but it contains less sodium than normal saline.
In a case of hyponatremia, it's better to use a solution with a higher sodium concentration, making choice A (normal saline) more appropriate.
Choice C rationale:
Lactated Ringer’s.
Rationale: Lactated Ringer's is another isotonic solution, but it may not be the best choice for a client with hyponatremia.
It contains lactate, which can be metabolized to bicarbonate, potentially worsening the client's hyponatremia.
Therefore, it's not the most appropriate option in this case.
Choice D rationale:
D5W (5% dextrose in water).
Rationale: D5W is a hypotonic solution and should not be used for rehydration in a client with hyponatremia.
It can exacerbate the electrolyte imbalance and is not suitable for addressing dehydration.
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale:
Gastrointestinal illnesses, including diarrhea and vomiting, lead to fluid loss, significantly contributing to dehydration in children.
Diarrhea increases water and electrolyte loss from the body, while vomiting leads to rapid fluid depletion.
These conditions can be severe, especially in infants and young children, making them prone to dehydration.
Choice B rationale:
Excessive sweating during physical activity or in hot weather can result in significant fluid loss.
Children, especially when engaged in vigorous activities, can sweat profusely, leading to dehydration, especially if fluid intake does not match the loss.
Monitoring fluid balance is crucial during such situations to prevent dehydration-related complications.
Choice C rationale:
Insufficient fluid intake due to poor feeding or decreased thirst perception can lead to dehydration, especially in infants and young children who rely heavily on fluid intake for their hydration needs.
Children may not recognize their thirst or may refuse to drink due to illness, leading to decreased fluid intake.
This can result in dehydration, emphasizing the importance of assessing feeding habits and fluid intake patterns.
Choice D rationale:
Sunken eyes and fontanelle in infants are physical signs of dehydration, not etiological factors.
Sunken eyes are due to decreased tissue turgor, indicating dehydration.
Fontanelle, the soft spot on an infant's head, can appear sunken in dehydration.
These signs are crucial in assessing the severity of dehydration during physical examination but do not contribute to the causes of dehydration.
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