The greatest threat to life in isotonic dehydration is:

Hypovolemic shock

Metabolic acidosis

Hypernatremia

Seizures

Answer and Explanation

The Correct Answer is A

Choice A reason: Isotonic dehydration involves equal loss of water and electrolytes, reducing circulating volume. This can lead to hypovolemic shock, characterized by hypotension and organ hypoperfusion, risking multi-organ failure. In children, rapid fluid loss from diarrhea or vomiting makes this the greatest life-threatening complication, requiring urgent fluid resuscitation.

Choice B reason: Metabolic acidosis may occur in dehydration from bicarbonate loss (e.g., diarrhea), but it is less immediately life-threatening than hypovolemic shock. Acidosis causes compensatory tachypnea but rarely leads to rapid death. Shock’s impact on perfusion is the primary threat, making acidosis a secondary concern in isotonic dehydration.

Choice C reason: Hypernatremia occurs in hypertonic dehydration, not isotonic, where sodium levels remain normal. Isotonic dehydration’s primary risk is volume depletion, leading to hypovolemic shock. Hypernatremia causes neurological symptoms but is not the main threat, as isotonic dehydration maintains electrolyte balance, making this incorrect.

Choice D reason: Seizures may occur in dehydration from electrolyte imbalances like hyponatremia, but isotonic dehydration maintains normal sodium levels, reducing seizure risk. Hypovolemic shock, from significant volume loss, is the greatest threat, causing cardiovascular collapse, making seizures a less immediate concern in this scenario.

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Correct Answer is C

Explanation

Choice A reason: Switching formula does not address projectile vomiting followed by hunger, suggestive of pyloric stenosis, a mechanical obstruction. Changing formula may delay diagnosis and treatment, risking dehydration or malnutrition. Immediate clinical evaluation is needed to confirm the condition and plan surgical intervention, making this response inappropriate.

Choice B reason: Frequent burping reduces air in the stomach but does not address projectile vomiting from pyloric stenosis, caused by pyloric muscle hypertrophy. This symptom requires surgical evaluation, not feeding adjustments. Burping is ineffective, as the obstruction persists, making clinical evaluation the priority to prevent complications.

Choice C reason: Projectile vomiting with hunger in a 2-month-old suggests pyloric stenosis, requiring urgent clinical evaluation for diagnosis via ultrasound and surgical planning (pyloromyotomy). Prompt assessment prevents dehydration, electrolyte imbalances, and growth issues, making this the appropriate response to ensure timely intervention for this serious condition.

Choice D reason: Oral rehydration solution treats dehydration but does not address the underlying cause of projectile vomiting, likely pyloric stenosis. This delays definitive surgical treatment, risking worsening dehydration or malnutrition. Clinical evaluation is critical to confirm the diagnosis, making rehydration a secondary, not primary, response to the symptoms.

A. Syrup of ipecac B. Vitamin K C. N-acetylcysteine D. Activated charcoal

Correct Answer is C

Explanation

Choice A reason: Syrup of ipecac is obsolete for acetaminophen overdose, as it delays definitive treatment like N-acetylcysteine. Acetaminophen causes hepatotoxicity via toxic metabolites, requiring specific antidote administration. Ipecac risks aspiration and is ineffective post-gastric lavage, making it an inappropriate choice for managing this potentially life-threatening overdose.

Choice B reason: Vitamin K treats bleeding from anticoagulant overdose, not acetaminophen toxicity, which causes hepatotoxicity by depleting glutathione, leading to liver damage. Vitamin K does not address acetaminophen’s metabolic effects, making it irrelevant. N-acetylcysteine is needed to restore glutathione and detoxify metabolites, making this choice incorrect.

Choice C reason: N-acetylcysteine is the antidote for acetaminophen overdose, replenishing glutathione to detoxify the toxic metabolite NAPQI, preventing liver damage. Administered post-gastric lavage, it reduces hepatotoxicity risk, especially if given within 8 hours of ingestion, making it the expected treatment to protect the child’s liver function.

Choice D reason: Activated charcoal adsorbs toxins in the gut but is less effective post-gastric lavage, as the stomach is already cleared. Acetaminophen’s rapid absorption requires N-acetylcysteine to prevent hepatotoxicity. Charcoal may be used early but is secondary to the antidote, making it less critical in this scenario.

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The greatest threat to life in isotonic dehydration is:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse working at a clinic speaks on the telephone with a parent of a 2-month-old infant. The parent tells the nurse that the infant has projectile vomiting followed by hunger after meals. Which of the following responses by the nurse is appropriate?

Correct Answer is C

Explanation

A child is brought to the emergency department because he ingested an unknown quantity of acetaminophen (Tylenol). What does the nurse expect this child to receive following gastric lavage?

Correct Answer is C

Explanation

A nurse is providing teaching to a parent of a child who has celiac disease. The nurse should include which of the following as an unacceptable food choice for this child?

A nurse is collecting data from a child who has acute appendicitis. Which of the following findings should the nurse expect?

Which instructions should the nurse give parents about caring for a child with acute glomerulonephritis with edema?

The greatest threat to life in isotonic dehydration is:

A nurse is caring for a 2-month-old child. The child’s provider has ordered a diphtheria, tetanus, and pertussis (DTaP) vaccine to be administered. Which of the following should cause the nurse to question the administration of this vaccine?

What nursing action would be avoided when caring for a child diagnosed with Wilms’ tumor?

A nurse is reinforcing teaching about self-administration of insulin with a parent of a school-age child who has a new diagnosis of diabetes mellitus. Which of the following statements by the parent indicates a need for further teaching?