A nurse is caring for a pediatric patient with suspected dehydration.
The child presents with diarrhea and vomiting.
What clinical manifestations would the nurse expect to observe in this patient?
Thirst and dry mouth.
Rapid heart rate and low blood pressure.
Sunken eyes and fontanelle in infants.
Lethargy and irritability.
The Correct Answer is C
Choice A rationale:
Thirst and dry mouth are common signs of dehydration in adults, but in pediatric patients, especially infants, the signs are different.
Children may not be able to communicate their thirst effectively, and dry mouth might not be as noticeable as other signs.
Choice B rationale:
Rapid heart rate and low blood pressure are symptoms of shock, which can occur in severe dehydration.
However, these symptoms are not specific to dehydration and can be present in other conditions.
Sunken eyes and fontanelle in infants are more specific indicators of dehydration in pediatric patients.
Sunken eyes occur due to loss of tissue turgor, and a sunken fontanelle (the soft spot on an infant's head) is a late sign of dehydration.
Choice D rationale:
Lethargy and irritability can be signs of dehydration, but they are nonspecific and can occur in various pediatric conditions.
Sunken eyes and fontanelle, on the other hand, are more specific to dehydration, especially in infants.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
“This fluid will help to restore my sodium levels and replace the fluids I lost from vomiting.”.
The client should understand that they are receiving Half Normal Saline (0.45% NaCl) to restore sodium levels and replace lost fluids due to vomiting.
Half Normal Saline contains 77 mEq/L of sodium and 77 mEq/L of chloride, making it a suitable choice for a patient with mild hyponatremia and fluid loss from vomiting.
It helps restore sodium levels without the risk of overcorrection seen with 0.9% NaCl.
Choice B rationale:
“This fluid will help to lower my sodium levels and replace the fluids I lost from sweating.”.
Half Normal Saline is not used to lower sodium levels; its purpose is to restore sodium levels and provide fluids for cases like vomiting or other fluid losses.
Sweating typically leads to fluid loss, not sodium loss, and Half Normal Saline is not a treatment for high sodium levels.
Choice C rationale:
“This fluid will help to restore my potassium levels and replace the fluids I lost from vomiting.”.
Half Normal Saline does not address potassium levels, and the primary reason for using it is to address sodium imbalances and fluid loss, not potassium-related issues.
Choice D rationale:
“This fluid will help to lower my potassium levels and replace the fluids I lost from sweating.”.
Half Normal Saline is not used to lower potassium levels and is not specifically indicated for treating high potassium.
Additionally, it is not typically used to address fluid loss from sweating.
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.
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