A nurse is caring for a toddler who has been vomiting for the past 8 hr. Which of the following findings indicates to the nurse that the child is dehydrated?
Increased blood pressure
Distended jugular veins
Flat anterior fontanel
Increased pulse
The Correct Answer is D
A. Increased blood pressure is typically not associated with dehydration. In fact, dehydration often causes hypotension or low blood pressure, especially in severe cases.
B. Distended jugular veins are usually a sign of fluid overload or heart failure, not dehydration. In dehydration, the veins may appear flat due to decreased fluid volume.
C. A flat anterior fontanel is generally expected in a well-hydrated child. A sunken fontanel would indicate dehydration in infants and young toddlers.
D. Increased pulse (tachycardia) is a common sign of dehydration. As the body loses fluid, the heart compensates by increasing the heart rate to maintain adequate perfusion of organs.
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Related Questions
Correct Answer is D
Explanation
A. Haemophilus influenzae type b (Hib) vaccination is typically given to infants and toddlers, not to children who are 11 years old. The child would likely have already received this vaccine as part of their early childhood immunizations.
B. Hepatitis A vaccination is recommended for children, but it is typically given earlier in childhood (around 1 year of age), and would not be given at 11 years old unless it is part of a catch-up schedule.
C. Rotavirus vaccination is given to infants, and by the age of 11, the child should have completed the recommended series.
D. The Human papillomavirus (HPV) vaccine is recommended for children ages 11 to 12 years, making it appropriate for this child. The nurse should plan to administer the HPV vaccine as part of routine immunizations for this age group.
Correct Answer is B
Explanation
A. Neck flexion when bending forward is not a typical indicator of scoliosis. Scoliosis is identified by abnormal curvature of the spine, not by the neck.
B. Uneven shoulders when standing erect are a key indicator of scoliosis. This asymmetry can be identified when the child bends forward at the waist, which is a standard test for scoliosis during a physical examination.
C. Toes that point inward when bending forward is not a sign of scoliosis. This could be indicative of a different musculoskeletal issue such as hip or leg alignment problems, but it is not related to scoliosis.
D. Knees that bow outward when standing erect indicate bow-leggedness (genu varum), not scoliosis. Scoliosis specifically affects the spine's curvature.
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