A nurse is caring for a toddler who has been vomiting for the past 8 hr. Which of the following findings indicates to the nurse that the child is dehydrated?
Increased blood pressure
Distended jugular veins
Flat anterior fontanel
Increased pulse
The Correct Answer is D
A. Increased blood pressure is typically not associated with dehydration. In fact, dehydration often causes hypotension or low blood pressure, especially in severe cases.
B. Distended jugular veins are usually a sign of fluid overload or heart failure, not dehydration. In dehydration, the veins may appear flat due to decreased fluid volume.
C. A flat anterior fontanel is generally expected in a well-hydrated child. A sunken fontanel would indicate dehydration in infants and young toddlers.
D. Increased pulse (tachycardia) is a common sign of dehydration. As the body loses fluid, the heart compensates by increasing the heart rate to maintain adequate perfusion of organs.
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Related Questions
Correct Answer is C
Explanation
A. Children with autism may have difficulty with social interactions and sensory processing. Placing them in a semiprivate room could cause distress due to the lack of control over the environment and may increase anxiety.
B. Maintaining eye contact with a child with autism, especially when agitated, may increase stress and exacerbate agitation. Many children with autism avoid eye contact and may find it uncomfortable.
C. Children with autism can be very sensitive to sensory input, including physical touch. Minimizing physical contact helps reduce sensory overload and the child’s anxiety.
D. While providing comforting stimuli can be beneficial, leaving the television on at night may disturb the child’s sleep or increase sensory overload, especially if they are sensitive to sounds or visual stimuli.
Correct Answer is C
Explanation
A. Neomycin is not a contraindication to the influenza vaccine. However, if a person has a known neomycin allergy, they should avoid specific vaccines containing neomycin, but this is not typically a concern with the influenza vaccine.
B. Gluten allergies are not a contraindication for the influenza vaccine. Gluten is not an ingredient in most influenza vaccines, so a gluten allergy would not impact vaccine administration.
C. The influenza vaccine contains trace amounts of egg proteins, and individuals who have had a severe allergic reaction (anaphylaxis) to eggs should not receive this vaccine, or they should receive it under close supervision with appropriate precautions. This is because egg-based production methods of the vaccine may pose a risk.
D. Gelatin is a common ingredient in some vaccines, but a gelatin allergy is not typically a contraindication for the influenza vaccine. However, if a child has a severe allergic reaction to gelatin, caution would be taken in administering the vaccine.
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