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: Performing an in/out catheterization is not a suitable method to measure urine output for a 10-month old client with dehydration. An in/out catheterization is a procedure where a catheter is inserted into the bladder through the urethra, and the urine is drained and measured. This method is invasive, painful, and carries the risk of infection and trauma. It is usually reserved for clients who have urinary retention or obstruction, or who need a sterile urine sample.
Choice B reason: Inserting a Foley catheter is also not an appropriate method to measure urine output for a 10-month old client with dehydration. A Foley catheter is a type of catheter that stays in the bladder and drains the urine into a collection bag. This method is also invasive, painful, and carries the risk of infection and trauma. It is usually used for clients who have urinary incontinence, surgery, or long-term bed rest.
Choice C reason: Collecting the client's urine in a cup is not a feasible method to measure urine output for a 10-month old client with dehydration. A cup is not a reliable or accurate device to collect and measure urine, especially for a young child who may not be toilet trained or cooperative. It is also difficult to ensure that all the urine is collected in the cup, and that the cup is not contaminated by other fluids or substances.
Choice D reason: Counting the number of wet diapers is the best method to measure urine output for a 10-month old client with dehydration. This method is non-invasive, simple, and practical. It can provide an estimate of the urine volume and frequency, and indicate the hydration status of the child. The nurse should weigh the diapers before and after use, and record the difference in grams. One gram of weight equals one milliliter of urine. The nurse should also observe the color, odor, and concentration of the urine. The normal urine output for a child is 1 to 2 mL/kg/hour.
Correct Answer is C
Explanation
Choice A reason: I will always need to take hydrocortisone pills is a correct statement. Hydrocortisone is a synthetic form of cortisol, a hormone that is normally produced by the adrenal glands. After a bilateral adrenalectomy, the patient will have no adrenal glands and will need to take hydrocortisone pills for life to replace the missing hormone.
Choice B reason: I have a way to inject hydrocortisone in case of emergency is also a correct statement. Hydrocortisone injections are used to treat acute adrenal crisis, a life-threatening condition that can occur when the patient has low cortisol levels due to stress, illness, injury, or surgery. The patient should have an emergency kit with hydrocortisone injections and instructions on how to use them.
Choice C reason: I will stop taking hydrocortisone when I feel better is an incorrect statement. This indicates a need for further education regarding medications after a bilateral adrenalectomy. The patient should never stop taking hydrocortisone without consulting their doctor, as this can cause severe symptoms of adrenal insufficiency, such as low blood pressure, low blood sugar, weakness, fatigue, and confusion.
Choice D reason: I have nausea or vomiting often is a statement that requires further assessment by the nurse. Nausea or vomiting can be signs of inadequate or excessive hydrocortisone dosage, or other complications after a bilateral adrenalectomy. The nurse should monitor the patient's vital signs, blood glucose, electrolytes, and weight, and report any abnormal findings to the doctor. The patient may need to adjust their hydrocortisone dose or take other medications to manage their symptoms.
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