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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. A decreased white blood cell (WBC) count in the cerebrospinal fluid (CSF) would not support the diagnosis of bacterial meningitis. Bacterial infections typically cause an increased WBC count, specifically neutrophils.
B. Elevated total protein in the CSF is a classic finding in bacterial meningitis, as the infection leads to increased permeability of the blood-brain barrier and results in an increase in protein content.
C. Elevated glucose in the CSF is not consistent with bacterial meningitis. In bacterial meningitis, glucose levels are usually decreased due to the consumption of glucose by bacteria.
D. Decreased pressure in the CSF is not typical in bacterial meningitis. Increased intracranial pressure often results in elevated CSF pressure.
Correct Answer is B
Explanation
A. Crushing sustained-release tablets is not recommended because it can alter the medication's intended effect, releasing it all at once, which can be dangerous for the child.
B. Allowing medications to flow into the tube by gravity is the correct method. It ensures the medication is delivered slowly and effectively, preventing the tube from clogging and ensuring proper absorption.
C. Flushing the tube with 2 mL of sterile water is insufficient after all medications are administered. Typically, the tube should be flushed with 15-30 mL of water before and after medication administration to ensure patency.
D. Mixing all medications together is not recommended because different medications may have incompatible properties, and mixing them could alter their effectiveness or cause adverse reactions. Each medication should be administered separately.
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