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 ["A","C","E"]
Explanation
Choice A rationale:
Administering oral rehydration solution (ORS) is a crucial nursing intervention for a dehydrated child.
ORS helps replenish the lost fluids and electrolytes, making it an effective treatment for dehydration.
Choice B rationale:
Keeping the child in a cold environment is not an appropriate intervention for a dehydrated child.
Dehydration is not related to room temperature, and maintaining a comfortable environment is important, but extreme cold could cause discomfort to the child.
Choice C rationale:
Monitoring the child's vital signs is an essential nursing intervention when caring for a dehydrated child.
Vital signs, including heart rate, respiratory rate, blood pressure, and temperature, can provide important information about the child's condition and hydration status.
Regular monitoring helps in assessing the child's progress and identifying any worsening symptoms.
Choice D rationale:
Providing heavy meals at regular intervals is not an appropriate intervention for a dehydrated child.
As mentioned earlier, heavy meals can be difficult to digest and may worsen dehydration.
It is more important to focus on rehydration with fluids like ORS.
Choice E rationale:
Educating the child and caregivers about dehydration is an important nursing intervention.
Teaching them about the signs and symptoms of dehydration, the importance of ORS, and how to prevent it in the future is essential for the child's well-being and for preventing future episodes of dehydration.
Correct Answer is C
Explanation
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.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.