A nurse is caring for a 4-year-old child who has dehydration. Which of the following findings should the nurse identify as the priority?

Sodium 142 mEq/L

Urine specific gravity 1.025

Potassium 2.5 mEq/L

Blood glucose 110 mg/Dl

Answer and Explanation

The Correct Answer is C

A. Sodium 142 mEq/L: This is within the normal range for sodium (135-145 mEq/L) and does not indicate a problem that needs immediate attention.

B. Urine specific gravity 1.025: This value is on the higher end of the normal range for urine specific gravity (1.010-1.030) and indicates concentration of urine, which can occur in mild dehydration. It is not critical but indicates the need for monitoring.

C. Potassium 2.5 mEq/L: This is below the normal range for potassium (3.5-5.0 mEq/L) and indicates hypokalemia, which can cause serious cardiac issues and muscle weakness. It is a priority to correct this imbalance to prevent complications.

D. Blood glucose 110 mg/dL: This is within the normal range for blood glucose levels (70-110 mg/dL) for children and does not indicate an immediate concern related to dehydration.

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Correct Answer is C

Explanation

A. Restrain the child's arms. Restraining the child's arms is unsafe and can cause injury. It is important to allow the seizure to occur without interference, except to ensure the child’s safety.

B. Insert a padded tongue blade into the child's mouth. This is an outdated and incorrect practice. Inserting anything into a seizing child's mouth can cause injury to the mouth or teeth and poses a choking hazard.

C. Place the child in a side-lying position. This is the correct action as it helps maintain an open airway and allows for drainage of saliva or vomit, reducing the risk of aspiration.

D. Elevate the child's legs on a pillow. This is not an appropriate action during a seizure as it does not address the safety and airway management needs of the child. Keeping the child on their side is more important for airway safety.

A. Ribbon Like, foul-smelling stools B. Chronic hunger C. Projectile vomiting D. Rigid abdomen

Correct Answer is A

Explanation

A. Ribbon Like, foul-smelling stools: Hirschsprung disease is characterized by a lack of nerve cells in parts of the colon, leading to obstruction and resulting in narrow, ribbon-like stools due to the passage through a narrowed section of bowel.

B. Chronic hunger: This is not typical for Hirschsprung disease. Children may actually have a poor appetite due to discomfort and constipation.

C. Projectile vomiting: Projectile vomiting is more commonly associated with pyloric stenosis, not Hirschsprung disease.

D. Rigid abdomen: While abdominal distention can occur due to severe constipation and fecal impaction, a rigid abdomen is more indicative of a more acute or severe abdominal condition, such as peritonitis or severe bowel obstruction.

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A nurse is caring for a 4-year-old child who has dehydration. Which of the following findings should the nurse identify as the priority?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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Correct Answer is A

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