A nurse is caring for a child who has been admitted with severe dehydration.
The nurse understands that the child’s degree of dehydration is typically classified based on the loss of body weight.
The nurse observes dry mucous membranes, decreased urine output, and decreased skin turgor in the child.
Based on these observations, the nurse should classify the child’s dehydration as:.
“Mild dehydration, which is 3-5% loss of body weight.”.
“Moderate dehydration, which is 6-9% loss of body weight.”.
“Severe dehydration, which is ≥10% loss of body weight.”.
“No dehydration, which is less than 3% loss of body weight.”..
The Correct Answer is C
“Severe dehydration, which is ≥10% loss of body weight.”.
Choice A rationale:
Mild dehydration is typically classified as a 3-5% loss of body weight.
The signs and symptoms described in the scenario, such as dry mucous membranes, decreased urine output, and decreased skin turgor, are indicative of more severe dehydration than a 3-5% loss.
Choice B rationale:
Moderate dehydration is generally considered to be a 6-9% loss of body weight.
However, the signs and symptoms presented in the scenario suggest a more severe state of dehydration.
Choice C rationale:
Severe dehydration is classified as a loss of ≥10% of body weight.
The signs and symptoms observed by the nurse, including dry mucous membranes, decreased urine output, and decreased skin turgor, are consistent with severe dehydration, making choice C The correct classification.
Choice D rationale:
No dehydration is defined as less than a 3% loss of body weight.
The clinical manifestations observed in the child, as described in the scenario, clearly indicate dehydration.
In this case, the child's signs and symptoms align with the classification of severe dehydration, which is characterized by a loss of ≥10% of body weight.
These symptoms include dry mucous membranes, decreased urine output, and decreased skin turgor.
It's crucial to recognize the severity of dehydration accurately to initiate the appropriate treatment and prevent complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
"The child's favorite foods and beverages" are not relevant when assessing dehydration.
While dietary habits are essential for overall health, they do not provide information about the child's hydration status.
Choice B rationale:
"The child's school attendance and activities" are unrelated to the assessment of dehydration.
School attendance and activities are important for a child's social and educational development but do not provide any insight into the child's fluid balance or hydration status.
Choice C rationale:
"The child's skin turgor and mucous membranes" are crucial indicators of dehydration during physical examination.
Poor skin turgor, where the skin tents or remains elevated after being pinched, suggests decreased tissue elasticity due to fluid loss.
Dry mucous membranes, including the mouth, indicate dehydration.
These signs provide immediate visual clues about the child's hydration status and guide further assessment and intervention.
Choice D rationale:
"The child's vaccination history" is not relevant to the assessment of dehydration.
While vaccination history is essential for preventive healthcare, it does not provide any information about the child's current hydration status or fluid balance.
Correct Answer is A
Explanation
Choice A rationale:
The client's statement, "This IV fluid will provide me with hydration and calories," is correct.
D10W contains 10% dextrose and is used to provide both hydration and calories to the patient.
Choice B rationale:
D10W would not help lower blood sugar levels.
In fact, it would increase blood sugar levels due to the high concentration of dextrose.
Choice C rationale:
D10W does not provide essential electrolytes, so the statement is incorrect.
It's primarily used for calorie supplementation and hydration.
Choice D rationale:
D10W would not help increase blood pressure.
While it can provide hydration, it does not contain medications or components specifically intended to increase blood pressure.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.