A nurse is providing interventions for a dehydrated child.
Select all appropriate nursing interventions from the following options (A-E).
"Administering oral rehydration solution (ORS).”..
"Keeping the child in a cold environment.”..
"Monitoring the child's vital signs.”..
"Providing heavy meals at regular intervals.”..
"Educating the child and caregivers about dehydration.”..
Correct Answer : A,C,E
Choice A rationale:
Administering oral rehydration solution (ORS) is a crucial nursing intervention for a dehydrated child.
ORS helps replenish the lost fluids and electrolytes, making it an effective treatment for dehydration.
Choice B rationale:
Keeping the child in a cold environment is not an appropriate intervention for a dehydrated child.
Dehydration is not related to room temperature, and maintaining a comfortable environment is important, but extreme cold could cause discomfort to the child.
Choice C rationale:
Monitoring the child's vital signs is an essential nursing intervention when caring for a dehydrated child.
Vital signs, including heart rate, respiratory rate, blood pressure, and temperature, can provide important information about the child's condition and hydration status.
Regular monitoring helps in assessing the child's progress and identifying any worsening symptoms.
Choice D rationale:
Providing heavy meals at regular intervals is not an appropriate intervention for a dehydrated child.
As mentioned earlier, heavy meals can be difficult to digest and may worsen dehydration.
It is more important to focus on rehydration with fluids like ORS.
Choice E rationale:
Educating the child and caregivers about dehydration is an important nursing intervention.
Teaching them about the signs and symptoms of dehydration, the importance of ORS, and how to prevent it in the future is essential for the child's well-being and for preventing future episodes of dehydration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E"]
Explanation
Sunken fontanelle (in infants).
C. Dry mucous membranes.
E. Lethargy.
Choice A rationale:
Sunken fontanelle (in infants) is a clinical sign of dehydration.
The fontanelle is the soft spot on an infant's head, and when it becomes sunken, it suggests that the child is dehydrated.
This occurs because a lack of adequate fluid causes the brain to temporarily shrink, leading to the sunken appearance.
Choice B rationale:
Increased urine output is not typically a sign of dehydration.
In fact, dehydration often leads to decreased urine output as the body attempts to conserve fluid.
Increased urine output can be a sign of other conditions, such as diabetes.
Choice C rationale:
Dry mucous membranes are a classic sign of dehydration.
When the body lacks sufficient fluids, the mucous membranes in the mouth and other areas can become dry and sticky.
This is an important clinical indicator of dehydration.
Choice D rationale:
Normal skin turgor is not a sign of dehydration.
Skin turgor refers to the skin's ability to bounce back when pinched and released.
In a hydrated individual, the skin should have good turgor.
Dehydration can lead to poor skin turgor, but normal skin turgor does not indicate dehydration.
Choice E rationale:
Lethargy is a potential sign of dehydration.
When a child is dehydrated, they may become lethargic or unusually tired because their body is not receiving the necessary fluids to function properly.
Lethargy can be an early sign of dehydration in children.
Correct Answer is A
Explanation
Choice A rationale:
Normal saline (0.9% NaCl).
Rationale: Normal saline is the most appropriate choice for a client with dehydration and hyponatremia.
It provides a balanced solution with sodium and chloride, which can help correct hyponatremia and rehydrate the client.
It is an isotonic solution and is commonly used for fluid resuscitation.
Choice B rationale:
Half normal saline (0.45% NaCl).
Rationale: Half normal saline is also an isotonic solution, but it contains less sodium than normal saline.
In a case of hyponatremia, it's better to use a solution with a higher sodium concentration, making choice A (normal saline) more appropriate.
Choice C rationale:
Lactated Ringer’s.
Rationale: Lactated Ringer's is another isotonic solution, but it may not be the best choice for a client with hyponatremia.
It contains lactate, which can be metabolized to bicarbonate, potentially worsening the client's hyponatremia.
Therefore, it's not the most appropriate option in this case.
Choice D rationale:
D5W (5% dextrose in water).
Rationale: D5W is a hypotonic solution and should not be used for rehydration in a client with hyponatremia.
It can exacerbate the electrolyte imbalance and is not suitable for addressing dehydration.
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