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 A
Explanation
A. Tell the client, "You seem to be very upset.": Using verbal de-escalation and acknowledging the client’s emotions can help reduce agitation. This approach demonstrates empathy, promotes communication, and can prevent escalation.
B. Use a face shield with a mask when providing care to the client: Personal protective equipment is important for infection control, but it does not address the behavioral escalation or help calm an agitated client.
C. Initiate seclusion protocol: Seclusion is a restrictive intervention used only if the client poses an imminent risk of harm. It is not the first step in managing agitation and should follow attempts at de-escalation.
D. Engage the panic alarm: Activating the panic alarm is appropriate in situations of immediate danger, but for verbal agitation and pacing without aggression, de-escalation is the first intervention.
Correct Answer is A
Explanation
Rationale:
A. Serum potassium: Spironolactone is a potassium-sparing diuretic that can cause hyperkalemia. Monitoring serum potassium is essential to detect elevated levels early and prevent cardiac complications.
B. Platelet count: Spironolactone does not significantly affect platelet production or function, so routine monitoring of platelets is not indicated for this medication.
C. Urine ketones: Ketone monitoring is relevant for clients with uncontrolled diabetes or ketosis, but it is not related to spironolactone therapy.
D. Total bilirubin: Bilirubin levels are used to assess liver function, which is not directly affected by spironolactone in most clients, so routine monitoring is not necessary unless the client has underlying hepatic disease.
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