A nurse is caring for an 8-month-old child admitted with dehydration. Which of the following client findings indicates that oral rehydration therapy has been effective? (Select all that apply)
Specific gravity of 1.010
Moist mucous membranes
Capillary refill less than 3 seconds
Sunken anterior fontanelle
Heart rate of 146/min
Correct Answer : A
Choice A reason:
A specific gravity of 1.010 indicates that the child’s urine is adequately diluted, suggesting proper hydration. Normal urine specific gravity ranges from 1.005 to 1.030. A value of 1.010 falls within this range and indicates that the kidneys are functioning well and the child is not dehydrated.
Choice B reason:
Moist mucous membranes are a sign of adequate hydration. When a child is well-hydrated, the mucous membranes in the mouth and other areas remain moist. This is a positive indicator that oral rehydration therapy has been effective in restoring the child’s fluid balance.
Choice C reason:
Capillary refill time of less than 3 seconds is another indicator of proper hydration and good peripheral perfusion. This means that the blood is circulating well throughout the body, and the tissues are receiving adequate oxygen and nutrients. A capillary refill time of less than 3 seconds is considered normal and suggests effective rehydration.
Choice D reason:
A sunken anterior fontanelle is a sign of dehydration in infants. When the fontanelle is sunken, it indicates that the child has lost a significant amount of fluid. Therefore, this finding does not indicate that oral rehydration therapy has been effective. Instead, it suggests that the child may still be dehydrated.
Choice E reason:
A heart rate of 146/min is elevated for an 8-month-old child1. Normal heart rates for infants range from 80 to 160 beats per minute. While this heart rate is within the upper limit of normal, it can also be a sign of dehydration or other stressors. Therefore, it is not a definitive indicator of effective rehydration therapy.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C"]
Explanation
The correct answer is a. Vomiting, c. Tachycardia.
Choice A: Vomiting
Vomiting is a common symptom of thyroid storm. Thyroid storm is a life-threatening condition that occurs when the thyroid gland releases a large amount of thyroid hormone in a short period. This sudden surge in thyroid hormone can cause severe metabolic disturbances, leading to symptoms such as vomiting. Vomiting can result from the body’s attempt to cope with the excessive thyroid hormone levels, which can affect the gastrointestinal system.
Choice B: Constipation
Constipation is not typically associated with thyroid storm. In fact, hyperthyroidism, including thyroid storm, usually causes an increase in bowel movements or diarrhea due to the accelerated metabolism. Constipation is more commonly associated with hypothyroidism, where the thyroid gland is underactive and slows down bodily functions.
Choice C: Tachycardia
Tachycardia, or a rapid heart rate, is a hallmark symptom of thyroid storm. The excessive thyroid hormones increase the body’s metabolic rate, leading to an increased demand for oxygen and nutrients. To meet this demand, the heart rate increases significantly, often exceeding 140 beats per minute. This rapid heart rate can be dangerous and requires immediate medical attention.
Choice D: Hypotension
Hypotension, or low blood pressure, is not a typical symptom of thyroid storm. Instead, thyroid storm often causes hypertension (high blood pressure) due to the increased metabolic activity and the body’s heightened demand for oxygen and nutrients. The cardiovascular system responds by increasing blood pressure to ensure adequate blood flow to vital organs.
Correct Answer is B
Explanation
The correct answer is b. Preadolescent growth spurt
Choice A reason:
Idiopathic scoliosis is not typically noticeable when a toddler begins to walk. At this stage, the spine is still developing, and any curvature is usually not significant enough to be detected. Idiopathic scoliosis most commonly becomes noticeable during periods of rapid growth, which occur later in childhood.
Choice B Reason:
The preadolescent growth spurt is the period when idiopathic scoliosis becomes most noticeable. This is because the rapid growth during this time can exacerbate the curvature of the spine. Idiopathic scoliosis often becomes apparent between the ages of 10 and 18 years, when children experience significant growth spurts.
Choice C Reason:
Late adolescence is not the period when idiopathic scoliosis becomes most noticeable. By this time, most children have completed their major growth spurts, and any scoliosis would likely have been detected earlier. The condition is typically identified during the preadolescent growth spurt.
Choice D Reason:
The newborn period is not associated with the development of idiopathic scoliosis. While congenital scoliosis can be present at birth, idiopathic scoliosis develops later in childhood, particularly during periods of rapid growth.
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