A nurse is assessing a toddler who has gastroenteritis and is exhibiting manifestations of dehydration. Which of the following findings should the nurse address first?
Hypotension
Tachypnea
Нурегругехіа
Skin breakdown
The Correct Answer is A
A. Hypotension is the most critical finding in dehydration, as it indicates severe fluid loss and can lead to shock. Immediate intervention is required to address the circulatory compromise.
B. Tachypnea is a compensatory response to dehydration and may not require as immediate attention as hypotension.
C. Hyperpyrexia (high fever) can occur in gastroenteritis but is less urgent compared to hypotension.
D. Skin breakdown is a concern in dehydrated patients, but hypotension poses a more immediate threat to life.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Palliative care can begin at any stage of a serious illness, not just when a prognosis of 6 months or less is given.
B. Palliative care addresses not only physical and mental needs but also social, emotional, and spiritual needs to improve the overall quality of life.
C. While the child's preferences are important, palliative care decisions are often made collaboratively with the family and healthcare team, rather than the child having the final say.
D. The primary goal of palliative care is to improve the quality of life for children and their families by managing symptoms and providing support.
Correct Answer is B
Explanation
A. A urinary output of 100 mL/hr is within the expected range for a 10-year-old and does not indicate septic shock. In early septic shock, urinary output is often preserved or mildly decreased.
B. An elevated temperature (fever) is a hallmark of early septic shock as the body mounts an inflammatory response to infection. Fever often accompanies early sepsis in pediatric patients.
C. Blood pressure may remain normal or slightly elevated in early septic shock due to compensatory mechanisms. A BP of 130/90 mm Hg is not a defining feature.
D. A heart rate of 60/min is abnormally low for a 10-year-old and could indicate late-stage shock or other complications. In early septic shock, tachycardia (elevated heart rate) is typically observed.
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