The nurse is monitoring for signs and symptoms of dehydration in a 1 year old child who has been hospitalized for diarrhea and prepares to take the child's temperature. Which method of temperature measurement should be avoided?
Orally
Tympanic
Rectal
Axillary
The Correct Answer is C
A. Orally: Oral temperature measurement is generally not suitable for a 1-year-old because they are often not able to cooperate, but it is not contraindicated for the child.
B. Tympanic: Tympanic (ear) temperature measurement is acceptable in children over 3 months old and is non-invasive.
C. Rectal: Rectal temperature should be avoided in infants and toddlers with diarrhea due to the risk of rectal trauma and infection. Diarrhea may also cause irritation to the rectal area, increasing the risk of injury.
D. Axillary: Axillary (underarm) temperature measurement is safe and commonly used in children, particularly for non-invasive monitoring.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Sodium 142 mEq/L: This is within the normal range for sodium (135–145 mEq/L) and does not indicate an immediate threat.
B. Potassium 2.5 mEq/L: This is critically low (normal range is 3.5–5.0 mEq/L), and hypokalemia can cause life-threatening cardiac arrhythmias.
C. Urine specific gravity 1.025: Although elevated, it is not as critical as severe hypokalemia.
D. Blood glucose 110 mg/dL: This is a normal glucose level and not a priority.
Correct Answer is B
Explanation
A. "I am hungry and thirsty.": Hunger and thirst are not concerning and may occur after fasting or due to nausea resolution.
B. "My belly doesn't hurt anymore.": A sudden decrease in abdominal pain may indicate rupture of the appendix, leading to peritonitis—a life-threatening emergency.
C. "I am scared and I want to go home.": This is a common emotional response in children facing surgery and not indicative of a medical emergency.
D. "I'm tired and want to take a nap.": Fatigue could result from illness but is less concerning than the potential for appendiceal rupture.
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