A client inquires about the signs of electrolyte imbalances in a dehydrated child.
Which symptoms should the nurse mention?
"Lethargy and muscle weakness.”..
"Increased appetite and hyperactivity.”..
"Shortness of breath and coughing.”..
"Excessive thirst and urination.”..
The Correct Answer is A
Choice A rationale:
Lethargy and muscle weakness are common signs of electrolyte imbalances in a dehydrated child.
Dehydration can lead to an imbalance of electrolytes, such as sodium and potassium, which affects muscle function and overall energy levels.
Choice B rationale:
Increased appetite and hyperactivity are not typical signs of electrolyte imbalances in a dehydrated child.
Dehydration often leads to a decreased appetite and lethargy.
Choice C rationale:
Shortness of breath and coughing are not directly related to electrolyte imbalances in a dehydrated child.
These symptoms are more likely to be associated with respiratory or pulmonary issues rather than dehydration.
Choice D rationale:
Excessive thirst and urination are common signs of dehydration but are not indicative of electrolyte imbalances.
These symptoms occur as the body attempts to compensate for fluid loss by increasing thirst and increasing urine output.
Electrolyte imbalances are more likely to manifest as muscle weakness and cardiac arrhythmias.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Vital signs are essential in assessing dehydration.
An elevated heart rate may indicate compensatory mechanisms due to decreased intravascular volume.
Low blood pressure may suggest severe dehydration, and abnormal temperature may indicate an underlying infection.
These parameters provide crucial information about the child's circulatory status, helping to assess the severity of dehydration.
Choice B rationale:
Physical examination findings, such as skin turgor and mucous membrane moisture, are valuable indicators of dehydration.
Poor skin turgor, where the skin doesn't return to its normal position promptly when pinched, indicates decreased tissue turgor due to fluid loss.
Dry mucous membranes, including the mouth, suggest dehydration and help evaluate the extent of fluid deficit.
These signs offer direct visual clues about the child's hydration status.
Choice C rationale:
Laboratory tests play a significant role in diagnosing dehydration.
A complete blood count (CBC) helps identify elevated hematocrit levels, indicating hemoconcentration due to fluid loss.
Electrolyte levels, specifically sodium and potassium, provide insights into the child's electrolyte balance, which can be disrupted in dehydration.
Urine specific gravity measures the kidney's ability to concentrate urine; a high specific gravity suggests concentrated urine due to reduced fluid intake.
These tests aid in confirming the diagnosis and assessing the severity of dehydration.
Choice D rationale:
Assessing the child's history is fundamental in understanding the underlying cause of dehydration.
Recent fluid intake and urine output patterns help determine the balance between intake and output.
Symptoms such as diarrhea, vomiting, and fever indicate potential causes of fluid loss.
Additionally, evaluating the child's overall health and any recent illnesses provides context for the dehydration, guiding appropriate treatment.
Correct Answer is A
Explanation
Choice A rationale:
“This fluid will help to increase your sodium levels which are currently too low.”.
The nurse should explain to the client that they are receiving Normal Saline (0.9% NaCl) to increase their sodium levels.
This is The correct choice because Normal Saline is a hypertonic solution containing 154 mEq/L of sodium and 154 mEq/L of chloride.
It is used in cases of hyponatremia to raise sodium levels.
Sodium is an essential electrolyte, and low levels can lead to symptoms such as weakness, confusion, and muscle cramps.
Choice B rationale:
“This fluid will help to decrease your sodium levels which are currently too high.”.
Normal Saline is a hypertonic solution that would not be used to lower sodium levels, as it would have the opposite effect and further elevate sodium levels.
Choice C rationale:
“This fluid will help to increase your potassium levels which are currently too low.”.
It is not used to increase potassium levels, and potassium replacement would require a different solution, such as potassium chloride.
Choice D rationale:
“This fluid will help to decrease your potassium levels which are currently too high.”.
Normal Saline does not address high potassium levels; it is used to address hyponatremia and dehydration by increasing sodium levels.
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