A nurse is assessing a dehydrated child for hydration status.
Select all the clinical signs and symptoms of dehydration that the nurse should consider.
Sunken fontanelle (in infants).
Increased urine output.
Dry mucous membranes.
Normal skin turgor.
Lethargy.
Correct Answer : A,C,E
Sunken fontanelle (in infants).
C. Dry mucous membranes.
E. Lethargy.
Choice A rationale:
Sunken fontanelle (in infants) is a clinical sign of dehydration.
The fontanelle is the soft spot on an infant's head, and when it becomes sunken, it suggests that the child is dehydrated.
This occurs because a lack of adequate fluid causes the brain to temporarily shrink, leading to the sunken appearance.
Choice B rationale:
Increased urine output is not typically a sign of dehydration.
In fact, dehydration often leads to decreased urine output as the body attempts to conserve fluid.
Increased urine output can be a sign of other conditions, such as diabetes.
Choice C rationale:
Dry mucous membranes are a classic sign of dehydration.
When the body lacks sufficient fluids, the mucous membranes in the mouth and other areas can become dry and sticky.
This is an important clinical indicator of dehydration.
Choice D rationale:
Normal skin turgor is not a sign of dehydration.
Skin turgor refers to the skin's ability to bounce back when pinched and released.
In a hydrated individual, the skin should have good turgor.
Dehydration can lead to poor skin turgor, but normal skin turgor does not indicate dehydration.
Choice E rationale:
Lethargy is a potential sign of dehydration.
When a child is dehydrated, they may become lethargic or unusually tired because their body is not receiving the necessary fluids to function properly.
Lethargy can be an early sign of dehydration in children.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is C
Explanation
Choice A rationale:
Vital signs are essential in assessing dehydration.
An elevated heart rate may indicate compensatory mechanisms due to decreased intravascular volume.
Low blood pressure may suggest severe dehydration, and abnormal temperature may indicate an underlying infection.
These parameters provide crucial information about the child's circulatory status, helping to assess the severity of dehydration.
Choice B rationale:
Physical examination findings, such as skin turgor and mucous membrane moisture, are valuable indicators of dehydration.
Poor skin turgor, where the skin doesn't return to its normal position promptly when pinched, indicates decreased tissue turgor due to fluid loss.
Dry mucous membranes, including the mouth, suggest dehydration and help evaluate the extent of fluid deficit.
These signs offer direct visual clues about the child's hydration status.
Choice C rationale:
Laboratory tests play a significant role in diagnosing dehydration.
A complete blood count (CBC) helps identify elevated hematocrit levels, indicating hemoconcentration due to fluid loss.
Electrolyte levels, specifically sodium and potassium, provide insights into the child's electrolyte balance, which can be disrupted in dehydration.
Urine specific gravity measures the kidney's ability to concentrate urine; a high specific gravity suggests concentrated urine due to reduced fluid intake.
These tests aid in confirming the diagnosis and assessing the severity of dehydration.
Choice D rationale:
Assessing the child's history is fundamental in understanding the underlying cause of dehydration.
Recent fluid intake and urine output patterns help determine the balance between intake and output.
Symptoms such as diarrhea, vomiting, and fever indicate potential causes of fluid loss.
Additionally, evaluating the child's overall health and any recent illnesses provides context for the dehydration, guiding appropriate treatment.
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