A nurse is planning care for a child who has severe diarrhea.
Which of the following actions is the nurse’s priority?
Introduce a regular diet
Maintain fluid therapy
Rehydrate
Assess fluid balance
The Correct Answer is D
The correct answer is choice D.
Choice A rationale:
Introducing a regular diet is not the immediate priority for a child with severe diarrhea. The focus should be on stabilizing the child’s condition before reintroducing regular foods.
Choice B rationale:
Maintaining fluid therapy is important, but it is part of the broader goal of managing fluid balance. It is not the first step in addressing severe diarrhea.
Choice C rationale:
Rehydration is crucial, but it falls under the broader category of assessing and managing fluid balance. Ensuring the child is properly hydrated is part of the overall assessment.
Choice D rationale:
Assessing fluid balance is the priority action. This involves evaluating the child’s hydration status, monitoring for signs of dehydration, and ensuring that fluid therapy is appropriately managed. This step is critical to prevent complications from severe diarrhea.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
While it’s true that bulimia nervosa can have serious health consequences, telling the patient that they “should stop because they need to” may come across as dismissive of the patient’s struggle. It’s important to remember that bulimia nervosa is a complex mental health disorder that often requires professional treatment.
Choice B rationale
Asking the patient why they engage in their behavior might seem like a logical question, but it could potentially make the patient feel defensive or blamed for their condition. It’s important to approach the conversation with empathy and understanding.
Choice C rationale
While it’s important to validate the patient’s feelings and experiences, saying “I’m proud of you for recognizing that this behavior is not normal” might not be the most therapeutic response. This statement could potentially reinforce the idea that their behavior is “abnormal,” which could lead to feelings of shame or guilt.
Choice D rationale
Expressing empathy and understanding, as in “It seems like you are feeling helpless about this behavior,” can be a therapeutic response. This statement acknowledges the patient’s feelings and opens up the conversation for further exploration of their experiences and potential coping strategies.
Correct Answer is C
Explanation
Choice A rationale
Hyperactive reflexes are not typically associated with hypokalemia. Hypokalemia, or low potassium levels in the blood, can cause muscle weakness, fatigue, constipation, and arrhythmia.
Choice B rationale
Extreme thirst is not a typical symptom of hypokalemia. It is more commonly associated with conditions such as diabetes.
Choice C rationale
A weak, irregular pulse is a common symptom of hypokalemia. Low levels of potassium can affect heart function, leading to abnormal heart rhythms.
Choice D rationale
Hyperactive bowel sounds are not typically associated with hypokalemia. In fact, constipation is a common symptom of this condition.
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