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 D
Explanation
Rationale:
A. Implement activities that promote the client's self-esteem: While boosting self-esteem can support smoking cessation, it is not the first priority. The nurse must first assess the client’s current coping strategies to tailor the cessation plan.
B. Offer a list of smoking cessation support groups: Providing resources is helpful, but without assessing the client’s needs and coping methods first, the support may not be appropriately matched to the client’s situation.
C. Provide education about the dangers of smoking: Education is important, but most clients are already aware of the health risks. Effective teaching requires first understanding the client's motivation and coping mechanisms.
D. Determine the client's coping methods: Assessment is always the initial step in the nursing process. Identifying how the client currently manages stress will help the nurse create an individualized and effective cessation plan.
Correct Answer is B
Explanation
A. Physical therapy: Physical therapists focus on improving mobility, balance, and strength. While important after a stroke, they do not primarily address swallowing difficulties.
B. Speech therapy: Speech-language pathologists assess and treat dysphagia (swallowing disorders) and communication difficulties. Referral to speech therapy ensures the client receives appropriate evaluation and interventions to prevent aspiration and maintain nutrition.
C. Respiratory therapy: Respiratory therapists manage airway and pulmonary function issues. They may assist if complications like aspiration pneumonia occur, but they do not directly treat swallowing difficulties.
D. Occupational therapy: Occupational therapists help with activities of daily living and adaptive strategies for self-care. While they may assist with feeding techniques or positioning, they do not specialize in swallowing assessments or interventions.
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