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
Choice A rationale:
Normal saline (0.9% NaCl).
Rationale: Normal saline is the most appropriate choice for a client with dehydration and hyponatremia.
It provides a balanced solution with sodium and chloride, which can help correct hyponatremia and rehydrate the client.
It is an isotonic solution and is commonly used for fluid resuscitation.
Choice B rationale:
Half normal saline (0.45% NaCl).
Rationale: Half normal saline is also an isotonic solution, but it contains less sodium than normal saline.
In a case of hyponatremia, it's better to use a solution with a higher sodium concentration, making choice A (normal saline) more appropriate.
Choice C rationale:
Lactated Ringer’s.
Rationale: Lactated Ringer's is another isotonic solution, but it may not be the best choice for a client with hyponatremia.
It contains lactate, which can be metabolized to bicarbonate, potentially worsening the client's hyponatremia.
Therefore, it's not the most appropriate option in this case.
Choice D rationale:
D5W (5% dextrose in water).
Rationale: D5W is a hypotonic solution and should not be used for rehydration in a client with hyponatremia.
It can exacerbate the electrolyte imbalance and is not suitable for addressing dehydration.
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.
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