A nurse is caring for a child who has been admitted with severe dehydration.
The nurse understands that the child’s degree of dehydration is typically classified based on the loss of body weight.
The nurse observes dry mucous membranes, decreased urine output, and decreased skin turgor in the child.
Based on these observations, the nurse should classify the child’s dehydration as:.
“Mild dehydration, which is 3-5% loss of body weight.”.
“Moderate dehydration, which is 6-9% loss of body weight.”.
“Severe dehydration, which is ≥10% loss of body weight.”.
“No dehydration, which is less than 3% loss of body weight.”..
The Correct Answer is C
“Severe dehydration, which is ≥10% loss of body weight.”.
Choice A rationale:
Mild dehydration is typically classified as a 3-5% loss of body weight.
The signs and symptoms described in the scenario, such as dry mucous membranes, decreased urine output, and decreased skin turgor, are indicative of more severe dehydration than a 3-5% loss.
Choice B rationale:
Moderate dehydration is generally considered to be a 6-9% loss of body weight.
However, the signs and symptoms presented in the scenario suggest a more severe state of dehydration.
Choice C rationale:
Severe dehydration is classified as a loss of ≥10% of body weight.
The signs and symptoms observed by the nurse, including dry mucous membranes, decreased urine output, and decreased skin turgor, are consistent with severe dehydration, making choice C The correct classification.
Choice D rationale:
No dehydration is defined as less than a 3% loss of body weight.
The clinical manifestations observed in the child, as described in the scenario, clearly indicate dehydration.
In this case, the child's signs and symptoms align with the classification of severe dehydration, which is characterized by a loss of ≥10% of body weight.
These symptoms include dry mucous membranes, decreased urine output, and decreased skin turgor.
It's crucial to recognize the severity of dehydration accurately to initiate the appropriate treatment and prevent complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E"]
Explanation
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.
Correct Answer is A
Explanation
Normal saline (0.9% NaCl).
Choice A rationale:
Normal saline (0.9% NaCl) is the most appropriate choice for a client with burns and hypovolemia.
This isotonic solution helps to restore intravascular volume and replace lost fluids.
It contains sodium chloride in a concentration similar to that of the body's extracellular fluid, making it effective for rehydration and replenishing electrolytes in hypovolemic patients.
Choice B rationale:
Half normal saline (0.45% NaCl) is a hypotonic solution with a lower sodium concentration than the body's extracellular fluid.
It is not the best choice for treating hypovolemia and burns because it may not effectively expand intravascular volume and may cause cellular swelling.
Choice C rationale:
Lactated Ringer's is an isotonic solution, but it contains additional electrolytes and lactate.
While it can be suitable for some fluid replacement needs, normal saline is preferred for burn patients because it has a simpler composition and is effective for volume resuscitation in cases of hypovolemia.
Choice D rationale:
D5W (5% dextrose in water) is a solution that primarily provides dextrose for energy, not suitable for hypovolemia and burns.
It can cause dilutional hyponatremia if used as the primary fluid in hypovolemic patients.
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