A nurse is providing care for a 6-year-old patient who was admitted due to dehydration following a tonsillectomy 26 hours ago.
The patient's vital signs are as follows: Temperature: 100.9°F, Pulse: 150 bpm (apically), Respiration: 28, Blood Pressure: 88/50, Pain: Ears 0, Throat 10 using FACES pain scale, Weight: 40 lbs.
Complete the following sentence by using the list of options as evidenced by: The patient is most at risk for:

Answer: D. Pulse of 150, poor skin turgor, oliguria, and an admission weight of 29.5 lbs. Rationale:

Choice A: A pulse of 160 is slightly elevated for a 3-year-old (normal range is 90-140 bpm), but not significantly so. Oliguria (decreased urine output) is a common sign of dehydration. However, sunken fontanels are typically seen in infants with severe

dehydration and not necessarily present in moderate cases. An admission weight of 30 lbs is irrelevant for assessing dehydration.

Choice B: A pulse of 180 is significantly elevated and suggests potential tachycardia, which can be a sign of severe dehydration or other underlying conditions. While a furrowed tongue can occur with dehydration, it's not specific enough. Mottled skin can be caused by various factors and isn't a definitive sign of moderate dehydration.

Admission weight alone isn't indicative of dehydration.

Choice C: A pulse of 120 is within the normal range for a 3-year-old. Dry mucous membranes are a common sign of dehydration. However, pale skin can be caused by various factors and isn't specific to dehydration. Admission weight alone isn't indicative of dehydration.

Choice D: A pulse of 150 is slightly elevated, potentially indicating dehydration or other factors. Poor skin turgor is a key assessment finding in moderate dehydration. It refers to the skin's slow return to its original shape after being pinched, indicating a lack of fluid. Oliguria is a common sign of dehydration, suggesting decreased fluid intake or output. An admission weight of 29.5 lbs might be slightly lower than the child's baseline weight due to dehydration, but weight alone shouldn't be used to diagnose dehydration.

Therefore, considering the combination of a slightly elevated pulse, poor skin turgor, oliguria, and a potential decrease in weight, choice D presents the most likely assessment findings in a child with moderate dehydration.

It's important to remember that a comprehensive assessment, including history, physical examination, and potentially laboratory tests, is crucial for diagnosing and classifying the severity of dehydration in children.

Choice A rationale

An 18-month-old who has a high fever, coughs hard, and has a runny nose requires urgent care. High fever in a child can be a sign of a serious infection or other medical condition. The hard coughing could indicate a respiratory issue such as bronchitis or pneumonia, which can be serious in young children. The runny nose is another symptom of a possible respiratory infection.

Choice B rationale

A one-year-old who has a slight fever, a rash, and green secretions may not require urgent care but should still be seen by a healthcare provider. A slight fever can be a sign of a minor infection, which may resolve on its own or with over-the-counter remedies. However, a rash

and green secretions could indicate a bacterial infection, which may require antibiotic treatment.