A child is hospitalized after a serious motor vehicle crash and has developed increased urination. What action by the nurse takes priority?
Restrict dietary sodium intake.
Assess the daily serum sodium level.
Weigh the child daily.
Monitor the child's intake and output.
The Correct Answer is D
In this scenario, the child's increased urination after a serious motor vehicle crash may
indicate a potential issue with fluid balance. Monitoring the child's intake and output is the
priority action for the nurse. This involves accurately measuring and recording the fluids the
child consumes (intake) and the fluids the child eliminates through urine, sweat, and other
sources (output). By closely monitoring the child's intake and output, the nurse can assess the
child's fluid status and identify any abnormalities or imbalances that may require further
intervention.
Restrict dietary sodium intake in (option A) is incorrect because restricting dietary sodium
intake, may be necessary in certain situations, such as if the child has a known sodium
imbalance or hypertension. However, it is not the priority action in this scenario.
Assess the daily serum sodium level in (option B) is incorrect because assessing the daily
serum sodium level, is important to evaluate the child's electrolyte balance. However, it is not
the priority action compared to monitoring the child's intake and output.
Weigh the child daily in (option C) is incorrect because weighing the child daily, is a useful
measure to assess changes in fluid balance. However, it is not the priority action in this
scenario compared to monitoring the child's intake and output, which provides real-time
information on fluid balance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The most important factor in determining the rate of fluid replacement in a dehydrated child
is urine output. Urine output is a crucial indicator of renal perfusion and hydration status.
Monitoring urine output allows healthcare professionals to assess the child's response to fluid
replacement therapy and adjust the rate accordingly.
The type of dehydration in (Option A) is incorrect. The type of dehydration, is important in
determining the appropriate fluid composition for rehydration but does not directly dictate the
rate of fluid replacement.
The child’s weight in (Option B) is incorrect. The child's weight, is considered when
calculating the maintenance fluid requirements, but it does not solely determine the rate of
fluid replacement for dehydration.
Serum potassium level in (Option D) is incorrect. The serum potassium level, is important to
monitor in a dehydrated child, especially in cases of severe dehydration, as electrolyte
imbalances may occur. However, it is not the most important factor in determining the rate of
fluid replacement. Fluid replacement is primarily guided by assessing the child's hydration
status through parameters such as urine output and clinical assessment.
Correct Answer is B
Explanation
Juvenile arthritis should be suspected in a child who exhibits joint swelling and pain lasting
longer than 6 weeks. Juvenile arthritis refers to a group of chronic inflammatory conditions
that affect the joints in children and adolescents. Persistent joint swelling and pain are
common symptoms of juvenile arthritis and are often accompanied by other signs such as
morning stiffness, limited range of motion, and joint warmth.
, frequent fractures in (option A) is not correct because it, is not typically associated with
juvenile arthritis. Fractures are more commonly associated with conditions affecting bone
strength, such as osteoporosis or certain genetic disorders.
lurching and abnormal gait with limited abduction in (option A) is not correct because it,
may be seen in certain musculoskeletal conditions or hip joint abnormalities, but it is not
specific to juvenile arthritis.
increased joint mobility in (option D) is incorrect because it, is not typically associated with
juvenile arthritis. In fact, joint stiffness and limited range of motion are more characteristic of
this condition.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today