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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Normal saline (0.9% NaCl).
Choice A rationale:
Normal saline (0.9% NaCl) is the most appropriate choice for a client with burns and hypovolemia.
This isotonic solution helps to restore intravascular volume and replace lost fluids.
It contains sodium chloride in a concentration similar to that of the body's extracellular fluid, making it effective for rehydration and replenishing electrolytes in hypovolemic patients.
Choice B rationale:
Half normal saline (0.45% NaCl) is a hypotonic solution with a lower sodium concentration than the body's extracellular fluid.
It is not the best choice for treating hypovolemia and burns because it may not effectively expand intravascular volume and may cause cellular swelling.
Choice C rationale:
Lactated Ringer's is an isotonic solution, but it contains additional electrolytes and lactate.
While it can be suitable for some fluid replacement needs, normal saline is preferred for burn patients because it has a simpler composition and is effective for volume resuscitation in cases of hypovolemia.
Choice D rationale:
D5W (5% dextrose in water) is a solution that primarily provides dextrose for energy, not suitable for hypovolemia and burns.
It can cause dilutional hyponatremia if used as the primary fluid in hypovolemic patients.
Correct Answer is C
Explanation
“Severe dehydration, which is ≥10% loss of body weight.”.
Choice A rationale:
Mild dehydration is typically classified as a 3-5% loss of body weight.
The signs and symptoms described in the scenario, such as dry mucous membranes, decreased urine output, and decreased skin turgor, are indicative of more severe dehydration than a 3-5% loss.
Choice B rationale:
Moderate dehydration is generally considered to be a 6-9% loss of body weight.
However, the signs and symptoms presented in the scenario suggest a more severe state of dehydration.
Choice C rationale:
Severe dehydration is classified as a loss of ≥10% of body weight.
The signs and symptoms observed by the nurse, including dry mucous membranes, decreased urine output, and decreased skin turgor, are consistent with severe dehydration, making choice C The correct classification.
Choice D rationale:
No dehydration is defined as less than a 3% loss of body weight.
The clinical manifestations observed in the child, as described in the scenario, clearly indicate dehydration.
In this case, the child's signs and symptoms align with the classification of severe dehydration, which is characterized by a loss of ≥10% of body weight.
These symptoms include dry mucous membranes, decreased urine output, and decreased skin turgor.
It's crucial to recognize the severity of dehydration accurately to initiate the appropriate treatment and prevent complications.
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