A nurse is providing interventions for a dehydrated child.
Select all appropriate nursing interventions from the following options (A-E).

Choice A rationale:

Administer electrolyte solutions or supplements as prescribed by the physician.

Rationale: While administering electrolyte solutions or supplements may be part of the treatment plan for a dehydrated child, it is not the initial action that the nurse should take.

The first step should be to assess the child's condition and monitor their response to treatment.

Choice B rationale:

Monitor the child’s response to treatment and adjust the plan accordingly.

Rationale: This is The correct answer.

Dehydration is a complex condition, and the nurse's initial action should be to closely monitor the child's response to treatment, which may include oral or intravenous rehydration.

By monitoring the child's vital signs, urine output, and clinical signs, the nurse can make real-time adjustments to the treatment plan.

Choice C rationale:

Collaborate with physicians, nutritionists, and other healthcare professionals to ensure comprehensive care.

Rationale: Collaboration with other healthcare professionals is important for the overall care of the child, but it is not the immediate action needed to correct electrolyte imbalances in a dehydrated child.

Monitoring and treatment adjustments come first.

Choice D rationale:

Assess the degree of dehydration based on clinical signs and symptoms.

Rationale: While assessing the degree of dehydration is important, it should not be the only action taken.

Monitoring the child's response to treatment and adjusting the plan is equally crucial.

Dehydration assessment is typically part of the initial evaluation, but ongoing monitoring is necessary to ensure the child's condition improves.

Choice A rationale:

Thirst and dry mouth are early signs of dehydration.

When the body loses fluids, it signals the brain to increase thirst and conserve water.

Dry mouth can occur due to reduced saliva production when the body is dehydrated.

Choice B rationale:

Decreased urine output and dark-colored urine are indicators of concentrated urine, suggesting dehydration.

Reduced fluid intake or excessive fluid loss can lead to decreased urine production, and the urine becomes more concentrated, appearing darker than usual.

Choice C rationale:

Rapid heart rate and low blood pressure are signs of hypovolemic shock, a severe form of dehydration where the body cannot circulate enough blood to meet its needs.

This can happen in severe cases of dehydration when there is a significant loss of fluids and electrolytes.

Choice D rationale:

Poor skin turgor is a classic clinical sign of dehydration.

Skin turgor refers to the skin's ability to return to its normal position after being pinched.

In dehydrated individuals, the skin loses elasticity and remains tented or "pinched" after being pulled up.

This indicates a lack of fluid in the body.

Choice E rationale:

Increased energy and playfulness are not typical signs of dehydration.

Dehydrated children are more likely to be lethargic and irritable due to the physiological stress on their bodies.