A nurse is assessing a child for dehydration.
Select all the clinical manifestations of dehydration in children mentioned in the text.
Thirst and dry mouth.
Decreased urine output and dark-colored urine.
Rapid heart rate and low blood pressure in severe cases.
Poor skin turgor.
Increased energy and playfulness.
Correct Answer : A,B,C,D
Choice A rationale:
Thirst and dry mouth are early signs of dehydration.
When the body loses fluids, it signals the brain to increase thirst and conserve water.
Dry mouth can occur due to reduced saliva production when the body is dehydrated.
Choice B rationale:
Decreased urine output and dark-colored urine are indicators of concentrated urine, suggesting dehydration.
Reduced fluid intake or excessive fluid loss can lead to decreased urine production, and the urine becomes more concentrated, appearing darker than usual.
Choice C rationale:
Rapid heart rate and low blood pressure are signs of hypovolemic shock, a severe form of dehydration where the body cannot circulate enough blood to meet its needs.
This can happen in severe cases of dehydration when there is a significant loss of fluids and electrolytes.
Choice D rationale:
Poor skin turgor is a classic clinical sign of dehydration.
Skin turgor refers to the skin's ability to return to its normal position after being pinched.
In dehydrated individuals, the skin loses elasticity and remains tented or "pinched" after being pulled up.
This indicates a lack of fluid in the body.
Choice E rationale:
Increased energy and playfulness are not typical signs of dehydration.
Dehydrated children are more likely to be lethargic and irritable due to the physiological stress on their bodies.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
“Severe dehydration, which is ≥10% loss of body weight.”.
Choice A rationale:
Mild dehydration is typically classified as a 3-5% loss of body weight.
The signs and symptoms described in the scenario, such as dry mucous membranes, decreased urine output, and decreased skin turgor, are indicative of more severe dehydration than a 3-5% loss.
Choice B rationale:
Moderate dehydration is generally considered to be a 6-9% loss of body weight.
However, the signs and symptoms presented in the scenario suggest a more severe state of dehydration.
Choice C rationale:
Severe dehydration is classified as a loss of ≥10% of body weight.
The signs and symptoms observed by the nurse, including dry mucous membranes, decreased urine output, and decreased skin turgor, are consistent with severe dehydration, making choice C The correct classification.
Choice D rationale:
No dehydration is defined as less than a 3% loss of body weight.
The clinical manifestations observed in the child, as described in the scenario, clearly indicate dehydration.
In this case, the child's signs and symptoms align with the classification of severe dehydration, which is characterized by a loss of ≥10% of body weight.
These symptoms include dry mucous membranes, decreased urine output, and decreased skin turgor.
It's crucial to recognize the severity of dehydration accurately to initiate the appropriate treatment and prevent complications.
Correct Answer is A
Explanation
Normal saline (0.9% NaCl).
Choice A rationale:
Normal saline (0.9% NaCl) is the most appropriate choice for a client with cerebral edema.
This isotonic solution is commonly used to maintain intravascular volume and provides a neutral effect on fluid balance in the brain.
It does not introduce additional electrolytes that could potentially worsen cerebral edema.
Choice B rationale:
Half normal saline (0.45% NaCl) is not the best choice for cerebral edema because it is hypotonic and may lead to cellular swelling, potentially exacerbating the edema.
Choice C rationale:
Lactated Ringer's, while isotonic, contains additional electrolytes and lactate.
In the case of cerebral edema, it is safer to use a solution with a simpler composition like normal saline to avoid any potential complications related to electrolyte imbalances.
Choice D rationale:
D5W (5% dextrose in water) is not recommended for cerebral edema because it contains dextrose and may not adequately address the underlying issue of increased intracranial pressure associated with cerebral edema.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.