A nurse is caring for a 7-year-old child who has severe dehydration. Which of the following findings should the nurse expect?
Blood pressure 94/68 mm Hg
Urinary output 30 mL/hr
Respiratory rate 24/min
Heart rate 152/min
The Correct Answer is D
A. A blood pressure of 94/68 mm Hg is within the normal range for a 7-year-old child and may indicate compensated dehydration rather than severe dehydration.
B. A urinary output of 30 mL/hr is insufficient and may indicate dehydration, but it does not specifically indicate severe dehydration.
C. A respiratory rate of 24/min is within the normal range for a 7-year-old child and is not specifically indicative of severe dehydration.
D. Tachycardia (heart rate >100 beats per minute) is a common finding in severe dehydration as the body attempts to compensate for decreased blood volume by increasing heart rate.
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Related Questions
Correct Answer is C
Explanation
A. A flat anterior fontanel can indicate dehydration in infants, so this finding does not indicate effective treatment.
B. Oliguria, or decreased urine output, is a sign of dehydration and would not indicate effective treatment.
C. Oral intake of 4 oz every 3 hours indicates that the infant is able to drink fluids and is likely rehydrated, indicating effective treatment.
D. A capillary refill of 4 seconds is prolonged and can indicate poor perfusion, which is not indicative of effective treatment for dehydration.
Correct Answer is A
Explanation
A.
A. Hallucinations - Delirium can cause perceptual disturbances such as hallucinations, where the client perceives things that are not actually present.
B. Agnosia - Agnosia refers to the inability to recognize familiar objects, which is not typically associated with delirium.
C. Bradycardia - Delirium is not typically associated with bradycardia; it may actually be associated with tachycardia due to the physiological stress response.
D. Aphasia - Aphasia refers to the loss of ability to understand or express speech, which is not typically associated with delirium.
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