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. Weighing the child weekly is not an appropriate intervention for managing acute diarrhea, as it does not address the immediate concern of dehydration or infection.
B. Keeping the child NPO for 12 hours is generally not recommended unless the child is severely dehydrated or vomiting, as it could lead to further dehydration. Hydration and appropriate refeeding are important in managing diarrhea.
C. A stool culture can help determine the cause of diarrhea (such as bacterial infection) and guide appropriate treatment. This is a priority in determining the underlying cause of the child's symptoms.
D. Offering apple juice is not recommended for diarrhea, as high fructose content can worsen diarrhea. Oral rehydration solutions (ORS) or clear fluids are more appropriate.
Correct Answer is C
Explanation
A. Aspirin is contraindicated for children due to the risk of Reye's syndrome, a potentially fatal condition associated with aspirin use in children under the age of 18.
B. Administering acetaminophen at this frequency could result in overdose or liver damage, especially in children. Acetaminophen should be given at appropriate intervals (usually every 4–6 hours) as per the prescribed dosage.
C. Lowering the temperature of the room can help reduce the child’s fever without overcooling. A comfortable room temperature helps to prevent further heat retention and promotes the child's comfort.
D. An ice bath can cause shivering, which could raise the body temperature and cause additional harm. It is not recommended for fever reduction in children.
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