A nurse is assessing a school-age child who has moderate dehydration due to diarrhea and vomiting. Which of the following manifestations should the nurse expect?
Decreased respirations
Polyuria
Bradycardia
Orthostatic hypotension
The Correct Answer is D
A. Decreased respirations: Moderate dehydration typically does not cause respiratory depression. Respiratory changes are more commonly associated with severe acid-base imbalances or advanced dehydration.
B. Polyuria: Dehydration leads to decreased fluid volume, which generally results in oliguria (reduced urine output) rather than polyuria. Increased urination is not an expected finding in moderate dehydration.
C. Bradycardia: Dehydration usually causes a compensatory increase in heart rate (tachycardia) to maintain cardiac output. Bradycardia is not typical unless there is a severe or underlying cardiac issue.
D. Orthostatic hypotension: Loss of fluid volume from diarrhea and vomiting can decrease circulating blood volume, leading to a drop in blood pressure upon standing. This is an expected cardiovascular manifestation of moderate dehydration in school-age children.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B,D,C,A
Explanation
Rationale:
B. Place the child in a sitting position: Positioning the child upright or with the head slightly tilted back promotes comfort, stability, and proper visualization of the conjunctival sac for accurate drop placement.
D. Pull the lower eyelid downward: This creates a conjunctival pocket that holds the medication and allows it to spread evenly over the eye surface without spilling.
C. Instill the drops of medication: Instillation should occur after exposing the conjunctival sac to ensure the medication reaches the target area. The dropper should not touch the eye to prevent contamination.
A. Apply pressure to the lacrimal punctum: This step is performed last to prevent systemic absorption of the medication by blocking the nasolacrimal duct. Holding gentle pressure for about 1 minute helps maximize the local effect of the drops.
Correct Answer is B
Explanation
A. Both fontanels are the same size: Fontanels differ in size and shape; the anterior is larger and diamond-shaped, while the posterior is smaller and triangular. Expecting them to be the same size is inaccurate.
B. The anterior fontanel is open: The anterior fontanel typically remains open until about 12–18 months of age. At 8 months, an open anterior fontanel is an expected finding and indicates normal skull development.
C. The posterior fontanel is open: The posterior fontanel usually closes by 6–8 weeks of age. An open posterior fontanel at 8 months may indicate delayed closure and should be evaluated further.
D. Both fontanels show molding: Molding refers to overlapping of cranial bones during birth. At 8 months, molding should no longer be present; its presence is not a normal finding at this age.
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