A nurse is assessing a child who has a suspected head injury. Which of the following actions should the nurse take to assess the child's cognitive status?

Choice A reason: A 109 ml/hour rate is excessive for a 13.5 kg child. Using the 4-2-1 rule (4 ml/kg/hour for the first 10 kg, 2 ml/kg/hour for the next 3.5 kg), the total is 47 ml/hour, not 109, which could cause fluid overload and cardiovascular strain.

Choice B reason: A 79 ml/hour rate overestimates maintenance fluids for a 13.5 kg child. The 4-2-1 rule yields 47 ml/hour (40 ml for 10 kg + 7 ml for 3.5 kg). Higher rates risk hypervolemia, potentially causing pulmonary edema or electrolyte imbalances in a child.

Choice C reason: For a 13.5 kg child, the 4-2-1 rule calculates maintenance fluids as 40 ml/hour (10 kg × 4 ml) + 7 ml/hour (3.5 kg × 2 ml) = 47 ml/hour, closest to 49 ml/hour. This rate maintains hydration without risking fluid overload, supporting renal and cardiovascular function.

Choice D reason: A 200 ml/hour rate is far too high for a 13.5 kg child, risking fluid overload, heart failure, or pulmonary edema. The correct maintenance rate, per the 4-2-1 rule, is approximately 47 ml/hour, making this choice dangerously excessive for pediatric fluid needs.

Choice A reason: Indicating a slow recovery is inappropriate as the first action in acute adrenal insufficiency, a life-threatening condition requiring immediate intervention. Hypocortisolism causes shock and metabolic instability, and addressing these urgently with fluids and cortisol takes precedence over prognostic discussions.

Choice B reason: Discussing imminent death is premature and inappropriate as the first step. Acute adrenal insufficiency is treatable with prompt administration of fluids and cortisol. Focusing on dire outcomes delays critical interventions needed to stabilize the child’s hemodynamic and metabolic status.

Choice C reason: Inserting an IV line to administer fluids and cortisol is the priority in acute adrenal insufficiency, which causes hypotension, hypoglycemia, and electrolyte imbalances due to cortisol deficiency. Rapid fluid resuscitation and cortisol replacement restore hemodynamic stability, prevent shock, and correct metabolic derangements, saving the child’s life.

Choice D reason: Preparing for ICU admission is secondary to immediate treatment in acute adrenal insufficiency. While ICU care may be needed, delaying IV fluids and cortisol risks cardiovascular collapse. Stabilization with fluids and hormone replacement is the urgent first step to address life-threatening symptoms.