A nurse is assessing a dehydrated child for hydration status.
Select all the clinical signs and symptoms of dehydration that the nurse should consider.
Sunken fontanelle (in infants).
Increased urine output.
Dry mucous membranes.
Normal skin turgor.
Lethargy.
Correct Answer : A,C,E
Sunken fontanelle (in infants).
C. Dry mucous membranes.
E. Lethargy.
Choice A rationale:
Sunken fontanelle (in infants) is a clinical sign of dehydration.
The fontanelle is the soft spot on an infant's head, and when it becomes sunken, it suggests that the child is dehydrated.
This occurs because a lack of adequate fluid causes the brain to temporarily shrink, leading to the sunken appearance.
Choice B rationale:
Increased urine output is not typically a sign of dehydration.
In fact, dehydration often leads to decreased urine output as the body attempts to conserve fluid.
Increased urine output can be a sign of other conditions, such as diabetes.
Choice C rationale:
Dry mucous membranes are a classic sign of dehydration.
When the body lacks sufficient fluids, the mucous membranes in the mouth and other areas can become dry and sticky.
This is an important clinical indicator of dehydration.
Choice D rationale:
Normal skin turgor is not a sign of dehydration.
Skin turgor refers to the skin's ability to bounce back when pinched and released.
In a hydrated individual, the skin should have good turgor.
Dehydration can lead to poor skin turgor, but normal skin turgor does not indicate dehydration.
Choice E rationale:
Lethargy is a potential sign of dehydration.
When a child is dehydrated, they may become lethargic or unusually tired because their body is not receiving the necessary fluids to function properly.
Lethargy can be an early sign of dehydration in children.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is A
Explanation
Choice A rationale:
“This fluid will help to restore my sodium levels and replace the fluids I lost from vomiting.”.
The client should understand that they are receiving Half Normal Saline (0.45% NaCl) to restore sodium levels and replace lost fluids due to vomiting.
Half Normal Saline contains 77 mEq/L of sodium and 77 mEq/L of chloride, making it a suitable choice for a patient with mild hyponatremia and fluid loss from vomiting.
It helps restore sodium levels without the risk of overcorrection seen with 0.9% NaCl.
Choice B rationale:
“This fluid will help to lower my sodium levels and replace the fluids I lost from sweating.”.
Half Normal Saline is not used to lower sodium levels; its purpose is to restore sodium levels and provide fluids for cases like vomiting or other fluid losses.
Sweating typically leads to fluid loss, not sodium loss, and Half Normal Saline is not a treatment for high sodium levels.
Choice C rationale:
“This fluid will help to restore my potassium levels and replace the fluids I lost from vomiting.”.
Half Normal Saline does not address potassium levels, and the primary reason for using it is to address sodium imbalances and fluid loss, not potassium-related issues.
Choice D rationale:
“This fluid will help to lower my potassium levels and replace the fluids I lost from sweating.”.
Half Normal Saline is not used to lower potassium levels and is not specifically indicated for treating high potassium.
Additionally, it is not typically used to address fluid loss from sweating.
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.