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
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Related Questions
Correct Answer is D
Explanation
A. Assess fluid balance: Although assessment is important, rehydration takes priority to address the acute loss of fluids and electrolytes.
B. Maintain fluid therapy: Fluid therapy maintenance is secondary to initiating rehydration.
C. Introduce a regular diet: Diet modification is less critical than rehydration in the acute phase.
D. Rehydrate: Rehydration addresses the immediate risk of dehydration and electrolyte imbalance caused by severe diarrhea.
Correct Answer is A
Explanation
A. Pedialyte: Pedialyte provides balanced electrolytes and fluid replacement, ideal for rehydration in diarrhea.
B. Broth: Broth may contain too much sodium, potentially worsening dehydration.
C. Apple juice: Apple juice is high in sugar, which can exacerbate diarrhea.
D. Cherry gelatin: Gelatin lacks electrolytes and nutrients needed for rehydration.
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