A nurse is assessing a child for dehydration.
Which of the following should the nurse evaluate during the physical examination?
"The child's favorite foods and beverages.”..
"The child's school attendance and activities.”..
"The child's skin turgor and mucous membranes.”..
"The child's vaccination history.”..
The Correct Answer is C
Choice A rationale:
"The child's favorite foods and beverages" are not relevant when assessing dehydration.
While dietary habits are essential for overall health, they do not provide information about the child's hydration status.
Choice B rationale:
"The child's school attendance and activities" are unrelated to the assessment of dehydration.
School attendance and activities are important for a child's social and educational development but do not provide any insight into the child's fluid balance or hydration status.
Choice C rationale:
"The child's skin turgor and mucous membranes" are crucial indicators of dehydration during physical examination.
Poor skin turgor, where the skin tents or remains elevated after being pinched, suggests decreased tissue elasticity due to fluid loss.
Dry mucous membranes, including the mouth, indicate dehydration.
These signs provide immediate visual clues about the child's hydration status and guide further assessment and intervention.
Choice D rationale:
"The child's vaccination history" is not relevant to the assessment of dehydration.
While vaccination history is essential for preventive healthcare, it does not provide any information about the child's current hydration status or fluid balance.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Gastrointestinal illnesses, particularly diarrhea and vomiting, lead to fluid loss from the body.
Diarrhea can cause significant loss of water and electrolytes, leading to dehydration.
Vomiting, especially when persistent, can also result in fluid depletion.
These conditions are common causes of dehydration in both children and adults.
Choice B rationale:
Excessive sweating during physical activity or in hot weather can lead to dehydration in individuals, but this scenario does not apply to the child described in the question, who is experiencing decreased urine output and dark-colored urine.
Sweating excessively is more common in older children and adults during physical activities.
Choice C rationale:
Fever, which increases the body's fluid requirements, is a valid point.
However, the child in this scenario does not have fever mentioned as a symptom.
In the absence of fever, gastrointestinal illnesses are the more likely cause of dehydration.
Choice D rationale:
Certain medical conditions, such as diabetes or kidney disease, can lead to chronic dehydration.
However, these conditions are not mentioned in the scenario provided.
In the absence of information about underlying medical conditions, gastrointestinal illnesses remain the most likely cause of the child's dehydration.
Correct Answer is A
Explanation
Choice A rationale:
“This fluid will help to increase your sodium levels which are currently too low.”.
The nurse should explain to the client that they are receiving Normal Saline (0.9% NaCl) to increase their sodium levels.
This is The correct choice because Normal Saline is a hypertonic solution containing 154 mEq/L of sodium and 154 mEq/L of chloride.
It is used in cases of hyponatremia to raise sodium levels.
Sodium is an essential electrolyte, and low levels can lead to symptoms such as weakness, confusion, and muscle cramps.
Choice B rationale:
“This fluid will help to decrease your sodium levels which are currently too high.”.
Normal Saline is a hypertonic solution that would not be used to lower sodium levels, as it would have the opposite effect and further elevate sodium levels.
Choice C rationale:
“This fluid will help to increase your potassium levels which are currently too low.”.
It is not used to increase potassium levels, and potassium replacement would require a different solution, such as potassium chloride.
Choice D rationale:
“This fluid will help to decrease your potassium levels which are currently too high.”.
Normal Saline does not address high potassium levels; it is used to address hyponatremia and dehydration by increasing sodium levels.
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