A nurse is assisting with the care of a 2-year-old child.
Click to highlight the findings that indicate the child has progressed. To deselect a finding, click on the finding again.
Day 3, 0900:
Weight
Bowel pattern
Sodium level
Respiratory rate
Urine specific gravity
Skin turgor
Heart rate
Weight
Bowel pattern
Sodium level
Respiratory rate
Urine specific gravity
Skin turgor
Heart rate
The Correct Answer is ["A","B","E","F","G"]
Rationale for correct choices:
• Weight: The child’s weight increased from 9.5 kg on day 2 to 10.2 kg on day 3, surpassing the admission weight of 10 kg. This indicates successful rehydration and restoration of fluid balance. Weight gain is a reliable objective marker of improvement in pediatric dehydration.
• Bowel pattern: The child’s stools changed from six watery stools on day 2 to two formed stools on day 3. This reflects resolution of diarrhea and recovery of gastrointestinal function. Normalization of bowel movements indicates that electrolyte and fluid losses have been addressed effectively.
• Urine specific gravity: Urine specific gravity decreased from 1.031 on admission to 1.018 on day 3. This reflects improved hydration status and kidney perfusion, as urine is less concentrated. Monitoring urine concentration helps evaluate the effectiveness of fluid replacement therapy.
• Skin turgor: Skin turgor improved from 2 seconds to less than 1 second and appears consistent with the child’s baseline. This indicates restored hydration and effective fluid therapy. Normal skin turgor demonstrates recovery from extracellular fluid deficit.
• Heart rate: The heart rate decreased from a tachycardic 116/min on Day 2 to 100/min on Day 3. A stable, lower heart rate indicates that the circulatory volume is adequate and the heart no longer needs to overcompensate for low blood volume.
Rationale for incorrect findings:
• Sodium level: Sodium remained within normal range (138 mEq/L), so while stable, it does not specifically indicate improvement beyond baseline.
• Respiratory rate: Respiratory rate remained mildly elevated at 26 breaths/minute; it shows stability but does not directly indicate recovery from dehydration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. The formula infusion rate of the feeding was too slow: A slow infusion rate generally decreases the risk of diarrhea because the gastrointestinal tract has more time to absorb nutrients. Rapid administration is more commonly associated with osmotic diarrhea due to overwhelming intestinal absorption capacity, so a slow rate is an unlikely cause.
B. The formula was given immediately following removal from the refrigerator: Cold formula can irritate the gastrointestinal mucosa and disrupt normal digestive enzyme activity, leading to increased motility and diarrhea. Allowing the formula to reach room or body temperature before administration helps reduce gastric upset and osmotic diarrhea.
C. The feeding tube was partially obstructed during the infusion: Partial obstruction typically slows or interrupts the flow of formula, which may cause bloating or nausea but does not usually result in diarrhea. The decreased delivery rate reduces intestinal osmotic load rather than triggering loose stools.
D. The client is experiencing delayed gastric emptying: Delayed gastric emptying slows the passage of formula into the small intestine, which can cause nausea, vomiting, or reflux, but it does not commonly cause diarrhea. Diarrhea is more associated with rapid gastric emptying or malabsorption rather than delayed emptying.
Correct Answer is B
Explanation
A. Vomiting: Vomiting is not a common adverse effect of electroconvulsive therapy (ECT). While anesthesia or premedication may occasionally cause nausea, it is not a typical expected response directly related to the ECT procedure itself.
B. Confusion: Transient confusion and short-term memory loss are common and expected adverse effects after ECT. Clients may experience disorientation immediately post-treatment, usually resolving within minutes to hours, and this is considered part of the normal recovery process.
C. Incontinence: Urinary or fecal incontinence is not typically associated with ECT. Motor control is usually intact post-procedure, and incontinence would indicate an unrelated neurological or medical issue.
D. Tinnitus: Ringing in the ears is not an expected effect of ECT. Auditory changes are not commonly reported, and if present, they should prompt further evaluation for other causes unrelated to the therapy.
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