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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. The nurse should notify the charge nurse of the situation to ensure that the client’s legal rights, autonomy, and best interests are considered in making decisions regarding treatment.

B. Offering an antiemetic is not the primary concern when the client is refusing treatment; the issue is the refusal of care.

C. Administering a sedative without addressing the underlying issue would not be appropriate and could violate the adolescent’s autonomy.

D. Starting the IV per the parent's request without the adolescent’s consent may violate the adolescent’s rights and should not be done without careful consideration of legal and ethical principles.

A. "I reported the incident to my supervisor who decided to contact the authorities." B. "I am unable to discuss this, but I can contact my supervisor to speak with you." C. "As a nurse, I am required by law to report suspected child abuse." D. "The provider will be coming to explain the situation."

Correct Answer is C

Explanation

A. While the nurse is required to report, it is not the supervisor’s decision. The nurse should clarify that they are the mandated reporter.

B. Deferring the explanation to the supervisor avoids the nurse’s responsibility. The nurse should directly explain their duty.

C. Nurses are mandated reporters and are legally required to report suspected child abuse. This response is appropriate as it aligns with the nurse’s professional and legal responsibilities.

D. The nurse should address the issue, not refer to the provider for an explanation of their actions.

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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?

Nursing Test Bank

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