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A nurse is assessing a child for dehydration.
Which of the following should the nurse evaluate during the physical examination?

A.

"The child's favorite foods and beverages.”..

B.

"The child's school attendance and activities.”..

C.

"The child's skin turgor and mucous membranes.”..

D.

"The child's vaccination history.”..

Answer and Explanation

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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Related Questions

Correct Answer is B

Explanation

Choice A rationale:

Maintaining a warm room temperature is not the key to preventing dehydration.

Dehydration occurs when the body loses more fluids than it takes in, and temperature control in the room doesn't directly address this issue.

Choice B rationale:

The significance of oral rehydration solution (ORS) is a crucial factor in preventing and treating dehydration.

ORS contains a balanced mixture of salts and sugars that help the body reabsorb water and electrolytes lost due to dehydration.

It is the most effective way to rehydrate a dehydrated child.

Educating the client about the importance of ORS is essential because it provides a clear solution to the problem of dehydration.

Choice C rationale:

The need for a complete blood count (CBC) testing is unrelated to the prevention of dehydration.

CBC is a diagnostic test used to assess various blood parameters, including red and white blood cell counts.

It is not a preventive measure against dehydration.

Choice D rationale:

Suggesting the child's need for frequent, heavy meals is not an appropriate way to prevent dehydration.

In fact, heavy meals can sometimes worsen dehydration as they may be difficult to digest, leading to an increased risk of vomiting and diarrhea, which exacerbate fluid loss.

Correct Answer is D

Explanation

The correct answer is Choice B: Total maintenance fluids = 1200 mL/day.

Choice A rationale:

This value exceeds the calculated requirement for a child weighing 18 kg using the Holliday-Segar method.

Choice B rationale:

The Holliday-Segar method calculates maintenance fluids based on weight as follows:

  • For the first 10 kg, the requirement is 100 mL/kg.
  • For the next 10 kg, the requirement is 50 mL/kg.

Thus, for a child weighing 18 kg:

  • First 10 kg: 10 kg x 100 mL/kg = 1000 mL
  • Next 8 kg: 8 kg x 50 mL/kg = 400 mL Total maintenance fluid requirement = 1000 mL + 400 mL = 1400 mL/day.

So, actually, the correct answer should be Choice D: 1400 mL/day.

Choice C rationale:

This value is higher than the requirement for 18 kg based on the Holliday-Segar method.

Choice D rationale:

This is the correct calculation based on the method described above: 1000 mL for the first 10 kg plus 400 mL for the next 8 kg totals 1400 mL/day.

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