A nurse in an emergency department is assessing an infant who is dehydrated. Which of the following findings should the nurse expect?
Irritability
Tetany
slow, bounding pulse
Decreased temperature
The Correct Answer is A
The nurse should expect to find irritability in an infant who is dehydrated. Dehydration in infants can lead to changes in behavior and irritability due to the imbalance in fluid and electrolytes. Other common signs of dehydration in infants may include:
Poor skin turgor (skin tenting)
Sunken fontanelles (soft spots on the baby's head)
Dry mucous membranes (dry mouth and tongue)
Decreased urine output or concentrated urine
Rapid heart rate (tachycardia)
Increased respiratory rate
Sunken eyes
Decreased tears when crying
B. Tetany is a condition characterized by involuntary muscle contractions and is more commonly associated with hypocalcemia (low calcium levels) rather than dehydration.
C. A slow, bounding pulse is not typically associated with dehydration. Dehydration often leads to a rapid heart rate (tachycardia) as the body attempts to compensate for the loss of fluid.
D. Decreased temperature is not a typical finding in dehydration. Dehydration can lead to fever in some cases due to an underlying infection, but it does not cause a decrease in body temperature on its own.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The nurse should clarify the prescription to administer sodium biphosphate/sodium phosphate because it is a laxative and is contraindicated in a child with suspected appendicitis. The use of laxatives or enemas can potentially worsen the condition by increasing the risk of perforation or rupture of the inflamed appendix.
A. Monitoring oral temperature every 4 hours is important to assess for signs of infection or worsening condition.
C. Maintaining NPO status is essential to avoid stimulating the digestive system and to prepare for possible surgery.
D. Medicating the client for pain every 4 hours as needed is appropriate to manage pain and provide comfort while the child awaits further evaluation or treatment.
Remember, it's crucial to avoid the use of laxatives, enemas, or any other interventions that can potentially aggravate the inflamed appendix in a child with suspected appendicitis.
Correct Answer is ["1250"]
Explanation
To calculate the daily fluid requirements for a child, you typically use the Holliday-Segar method, which provides guidelines based on the child's weight:
- For the first 10 kg of body weight, you give 100 ml per kg.
- For the second 10 kg of body weight, you give 50 ml per kg.
- For any weight above 20 kg, you give 20 ml per kg.
First, convert the child's weight from pounds to kilograms. To do this, divide the weight in pounds by 2.2.
For a child weighing 33 pounds:
- The weight in kilograms is approximately 15 kg (33 divided by 2.2).
Now, calculate the fluid requirement:
- For the first 10 kg of the child's weight, you need 1000 ml (10 kg multiplied by 100 ml).
- For the remaining 5 kg, you need 250 ml (5 kg multiplied by 50 ml).
Adding these together, the total daily fluid requirement is 1250 ml.
So, the daily fluid requirement for a child weighing 33 pounds is 1250 ml.
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