A nurse is assisting with the care of a 2-year-old child.
Complete the following sentence by using the lists of options.
The child is at risk for developing
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
Rationale for correct choices:
- Dehydration: The child has ongoing vomiting and six watery stools within 24 hours, along with fever and decreased activity, all of which increase fluid loss. Clinical findings such as sunken eyes, elevated heart rate, weight loss of 0.5 kg, elevated hemoglobin and hematocrit, and increased urine specific gravity indicate hemoconcentration. Reduced urine output over 24 hours further reflects inadequate fluid balance. These findings support worsening dehydration.
- Bowel elimination: Frequent watery stools secondary to Escherichia coli infection significantly increase fluid and electrolyte losses. Diarrhea accelerates intestinal transit, reducing absorption of water and sodium. Continuous gastrointestinal losses place toddlers at high risk for rapid volume depletion. Altered bowel elimination is the primary contributing factor to dehydration.
Rationale for incorrect choices
- Seizures: Although electrolyte imbalance can contribute to seizure risk, this child’s sodium level remains within normal limits. There is no evidence of neurological irritability, altered consciousness beyond drowsiness from illness, or severe hyponatremia. The primary concern is fluid volume loss rather than neurologic instability.
- Malnutrition: The child has had decreased appetite for two days, but malnutrition develops over a longer period of inadequate intake. The more urgent issue is acute fluid loss rather than caloric deficiency. Short-term decreased intake combined with diarrhea primarily leads to dehydration.
- Respiratory distress: The child’s oxygen saturation remains stable at 95–98% on room air, and respiratory findings do not indicate compromise. Although respiratory rate is mildly elevated, this can be related to fever or metabolic compensation. There are no signs of increased work of breathing or hypoxia. Respiratory distress is not supported by the data.
- Appetite: While decreased appetite contributes to reduced oral intake, it is not the main mechanism causing rapid fluid depletion. The significant losses are occurring through persistent diarrhea and vomiting. Appetite changes alone would not account for the weight loss and concentrated urine. Bowel elimination is the stronger contributing factor.
- Oxygenation status: Oxygen saturation levels are within acceptable limits and do not indicate impaired gas exchange. There is no cyanosis, retractions, or abnormal lung findings reported. Oxygenation does not contribute to the child’s fluid imbalance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. A client who had surgery for cataract removal and lives in a rural location: Cataract surgery is typically an outpatient procedure with predictable recovery and minimal long-term care needs. While follow-up and access to care may require some coordination, it does not usually necessitate an interdisciplinary care conference, as care needs are straightforward.
B. A client who has hemiparesis and lives alone: Hemiparesis significantly impacts mobility, self-care, and safety, and living alone increases the risk of complications such as falls, inadequate nutrition, or medication mismanagement. An interdisciplinary care conference involving nursing, physical and occupational therapy, social work, and possibly home health services is essential to develop a comprehensive discharge plan.
C. A client who requires assistance to pay for dressing supplies: Financial assistance is primarily a social service concern and can usually be addressed by social work without convening a full interdisciplinary care conference. Coordination is needed, but the client’s clinical care needs are otherwise routine.
D. A client who requires instruction regarding medication administration: Teaching about medications is a standard nursing responsibility and can be managed with routine patient education. While education is important, it does not necessitate an interdisciplinary care conference unless other complex care needs exist.
Correct Answer is ["C","E","F"]
Explanation
A. Laboratory electrolyte levels: The client’s potassium (3.7 mEq/L) and sodium (137 mEq/L) are within expected reference ranges. These values do not indicate electrolyte imbalance or metabolic instability that would require holding the feeding. Electrolyte disturbances can occur with enteral nutrition, but current results do not support discontinuation.
B. Oxygen saturation: An oxygen saturation of 96% on room air reflects adequate oxygenation and does not indicate aspiration or respiratory compromise. If aspiration from tube feeding had occurred, decreased oxygen saturation or respiratory distress might be present. Current findings do not justify holding the feeding based on oxygenation status.
C. Abdominal findings: A distended, firm, and tense abdomen suggests possible feeding intolerance, delayed gastric emptying, or bowel obstruction. These findings increase the risk for regurgitation and aspiration if feeding continues. Abdominal distention in the presence of enteral nutrition warrants holding the feeding and notifying the provider for further evaluation.
D. Blood glucose: A blood glucose of 152 mg/dL falls within the prescribed correction scale requiring 2 units of regular insulin. Mild hyperglycemia is common with enteral feedings and is addressed with sliding-scale insulin as ordered. This value alone does not require stopping the feeding.
E. Gastric residual: A gastric residual of 90 mL may indicate delayed gastric emptying, particularly when accompanied by abdominal distention. Elevated residual volumes increase the risk of aspiration if feeding continues. Clinical context, including abdominal findings, supports holding the feeding and notifying the provider.
F. pH of gastric contents: A pH of 6.4 is higher than expected for gastric contents, which are typically acidic (pH ≤5). An elevated pH raises concern for possible tube displacement into the respiratory tract or small intestine. This finding requires further verification of placement before continuing feedings.
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