An 18-month-old is brought to the emergency department with severe dehydration and weight loss secondary to acute diarrhea and vomiting. The nurse knows that therapeutic management of this child will begin with:
Administration of an anti-diarrheal
Clear liquids, 1 to 2 ounces at a time
Oral rehydration solution (ORS)
Intravenous fluids
The Correct Answer is C
Choice A reason: Administration of an anti-diarrheal is not the appropriate management for an 18-month-old with severe dehydration and weight loss secondary to acute diarrhea and vomiting. Anti-diarrheals are not recommended for children under 5 years, as they can have serious side effects, such as paralytic ileus, toxic megacolon, and worsening of dehydration. Anti-diarrheals do not address the underlying cause of diarrhea, and may prolong the duration of infection or toxin exposure.
Choice B reason: Clear liquids, 1 to 2 ounces at a time, are not sufficient to treat an 18-month-old with severe dehydration and weight loss secondary to acute diarrhea and vomiting. Clear liquids, such as water, tea, or broth, do not contain enough electrolytes, such as sodium, potassium, and bicarbonate, to replace the losses from diarrhea and vomiting. Clear liquids may also dilute the blood sodium level and cause hyponatremia, a condition of low sodium in the blood, which can lead to seizures, coma, and death.
Choice C reason: Oral rehydration solution (ORS) is the best management for an 18-month-old with severe dehydration and weight loss secondary to acute diarrhea and vomiting. ORS is a specially formulated solution that contains water, glucose, and electrolytes in the right proportions to replenish the fluid and electrolyte losses from diarrhea and vomiting. ORS can prevent or treat dehydration, and reduce the need for intravenous fluids. ORS can be given by mouth, spoon, cup, or syringe, depending on the child's ability to drink. The amount of ORS to give depends on the degree of dehydration and the weight of the child. The nurse should follow the guidelines from the World Health Organization (WHO) or the local health authority for the appropriate dosage and frequency of ORS administration¹.
Choice D reason: Intravenous fluids are not the first-line management for an 18-month-old with severe dehydration and weight loss secondary to acute diarrhea and vomiting. Intravenous fluids are only indicated for children who have severe dehydration and are unable to drink or tolerate ORS, or who have signs of shock, such as weak pulse, cold extremities, or altered consciousness. Intravenous fluids require hospitalization, skilled personnel, and sterile equipment, and carry the risk of infection, overhydration, or electrolyte imbalance. Intravenous fluids should be given according to the WHO or the local health authority guidelines, and should be switched to ORS as soon as the child is able to drink¹.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This statement is false. A sugar-water pacifier does not help the vaccination be more effective. Vaccinations are effective because they stimulate the immune system to produce antibodies against a specific disease.
Choice B reason: This statement is false. A sugar-water pacifier does not prevent hypoglycemia from the stress of the injection. Hypoglycemia is a condition where the blood sugar level is too low, which can cause symptoms such as sweating, trembling, confusion, or seizures. A sugar-water pacifier does not provide enough glucose to prevent hypoglycemia.
Choice C reason: This statement is false. A sugar-water pacifier does not provide additional calories to prevent malnourishment. Malnourishment is a condition where the body does not get enough nutrients, such as protein, vitamins, and minerals, to function properly. A sugar-water pacifier does not provide enough nutrients to prevent malnourishment.
Choice D reason: This statement is true. A sugar-water pacifier soothes and distracts the infant from pain. Sugar-water has a sweet taste that activates the endorphin system, which reduces pain perception. A pacifier also provides oral stimulation and comfort, which distracts the infant from the pain of the injection.
Correct Answer is ["B","C"]
Explanation
Choice A reason: Foot inspection is not an annual/yearly screening, but a daily self-care practice for people with diabetes. Foot inspection involves checking the feet for any signs of injury, infection, or ulceration, such as cuts, blisters, redness, swelling, or drainage. Foot inspection can help prevent or detect foot problems, such as neuropathy, ischemia, or infection, which can lead to amputation if left untreated. The nurse should teach Jo how to inspect his feet every day, and how to care for his feet, such as washing, drying, moisturizing, trimming nails, and wearing proper footwear.
Choice B reason: Serum creatinine (Cr) is an annual/yearly screening for people with diabetes. Serum creatinine is a blood test that measures the level of creatinine, a waste product that is filtered by the kidneys. Serum creatinine can indicate the kidney function, and detect kidney damage or disease, which is a common complication of diabetes. The nurse should explain to Jo that he needs to have his serum creatinine checked every year, and that he should keep his blood glucose and blood pressure under control, as these are the main risk factors for kidney problems.
Choice C reason: Chest X-ray is not an annual/yearly screening for people with diabetes, unless they have symptoms or risk factors for lung diseases, such as tuberculosis, pneumonia, or cancer. Chest X-ray is an imaging test that uses X-rays to produce pictures of the lungs and the chest cavity. Chest X-ray can help diagnose or monitor lung conditions, such as infections, inflammations, or tumors. The nurse should ask Jo about his history of smoking, exposure to environmental pollutants, or respiratory symptoms, such as cough, shortness of breath, or chest pain, and refer him to a doctor if he needs a chest X-ray.
Choice D reason: White blood cell count (WBC) is not an annual/yearly screening for people with diabetes, unless they have signs or risk factors for infections, such as fever, wounds, or immunosuppression. White blood cell count is a blood test that measures the number and types of white blood cells, which are the cells that fight infections and inflammation. White blood cell count can help diagnose or monitor infections, such as bacterial, viral, or fungal infections, or immune disorders, such as allergies, autoimmune diseases, or cancers. The nurse should assess Jo for any signs of infection, such as fever, chills, malaise, or pus, and advise him to seek medical attention if he has any.
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