A nurse is caring for an 8-month-old infant who has received a bolus of IV fluid for hypovolemic shock. Which of the following findings indicates the treatment was effective?
Temperature 38.6° C (101.5° F)
Sunken anterior fontanel
Tachycardia
Capillary refill is 2 seconds
The Correct Answer is D
A. "Temperature 38.6° C (101.5° F)." A fever is not an indicator of improved hydration or effective fluid resuscitation. It may be related to an underlying infection, which could contribute to hypovolemia.
B. "Sunken anterior fontanel." A sunken fontanel is a sign of dehydration, indicating that the fluid replacement was not fully effective. If the treatment were successful, the fontanel should be normal (flat and soft).
C. "Tachycardia." Tachycardia is a sign of ongoing hypovolemia or distress. If fluid resuscitation was effective, the heart rate should return to normal for the infant's age.
D. "Capillary refill is 2 seconds." A capillary refill time of 2 seconds or less indicates adequate peripheral perfusion and improved circulation, showing that the fluid bolus was effective in restoring blood volume and perfusion.
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Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}
Explanation
Disseminated Intravascular Coagulation (DIC)- Bacterial meningitis can lead to septicemia, which may trigger DIC. Petechiae or purpura (noted earlier) suggest potential coagulation abnormalities. DIC results in widespread clotting and subsequent bleeding, which can be life-threatening.
Hydrocephalus- Meningeal inflammation can obstruct cerebrospinal fluid (CSF) flow, leading to increased intracranial pressure (ICP). Symptoms such as headache, lethargy, irritability, and nuchal rigidity suggest increased ICP and potential hydrocephalus development.
Hypothermia- The child presents with fever (38.7°C/101.7°F), which is typical in bacterial infections rather than hypothermia. Septic shock can cause hypothermia in late stages, but early-stage bacterial meningitis more commonly causes fever.
Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"A","dropdown-group-3":"B"}
Explanation
Gastrointestinal: Iron is better absorbed when the stomach is empty, so administering it between meals is the best approach to enhance its effectiveness.
Dental: Iron supplements can cause staining of the teeth, so brushing after taking the supplement will help prevent this issue.
Hematological: After a month of treatment with iron supplements, a follow-up blood test is necessary to evaluate the improvement in hemoglobin levels and to ensure the treatment is effective.
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