A young child is brought to the emergency department with severe dehydration secondary to acute diarrhea and vomiting. Therapeutic management of this child will begin with which intervention?
Clear liquids, 1 to 2 ounces at a time.
Administration of antidiarrheal medication.
Oral rehydration solution (ORS).
Intravenous fluids.
The Correct Answer is C
The correct answer is choice C: Oral rehydration solution (ORS).
Choice A rationale:
Clear liquids, 1 to 2 ounces at a time, might not be sufficient to adequately rehydrate a child with severe dehydration. Clear liquids lack the necessary electrolytes and glucose content to effectively combat dehydration and replace lost fluids.
Choice B rationale:
Administration of antidiarrheal medication is not the initial step in managing severe dehydration caused by acute diarrhea and vomiting. Antidiarrheal medications can slow down the gastrointestinal motility, which may exacerbate the problem by delaying the elimination of the causative agent and prolonging the dehydration.
Choice C rationale:
Oral rehydration solution (ORS) is the recommended initial intervention for managing severe dehydration caused by acute diarrhea and vomiting. ORS contains the appropriate balance of electrolytes (sodium, potassium, chloride) and glucose to replace lost fluids and electrolytes, thereby helping to rehydrate the child effectively. It is absorbed even when digestion is impaired due to the illness.
Choice D rationale:
Intravenous fluids might be necessary if the child's condition is very severe and oral intake cannot be maintained. However, it's not the first-line intervention. Oral rehydration is preferred whenever feasible because it is less invasive and can be administered even in mild to moderate dehydration cases.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B: Lesions may extend to hairline or neck.
Choice A rationale:
Central clearing is not a prominent indicator of Tinea capitis. Tinea capitis is a fungal infection of the scalp and hair shafts, commonly caused by dermatophytes like Trichophyton species. The characteristic features include scaling, erythema, pustules, and hair loss. Unlike some other fungal infections, Tinea capitis does not typically have central clearing.
Choice B rationale:
Lesions extending to the hairline or neck is a correct aspect to include in education about Tinea capitis. The infection usually starts as small, scaly patches on the scalp and can progress to larger areas. It can extend to the hairline, neck, and even eyebrows and eyelashes. This is important information to convey to ensure proper recognition and timely treatment.
Choice C rationale:
Transmission of Tinea capitis mostly occurs from human-to-human rather than from dogs. While some animals can carry fungal infections that affect the skin, Tinea capitis is primarily spread through direct contact with an infected person or contaminated objects like combs, hats, and pillows.
Choice D rationale:
The appearance of Tinea capitis is not usually unilateral. This condition often presents with multiple, scattered areas of involvement on the scalp. It can cause varying degrees of inflammation, scaling, and hair loss in different areas, which may not follow a unilateral pattern.
Correct Answer is C
Explanation
The correct answer is choice C. Activity intolerance related to generalized weakness.
Choice A rationale:
Risk for injury related to depressed sensorium. This choice is not the most appropriate nursing diagnosis for a child with moderate anemia. While anemia can lead to fatigue and weakness, the main concern is the child's ability to tolerate physical activities, not the risk of injury due to a depressed sensorium.
Choice B rationale:
Decreased cardiac output related to abnormal hemoglobin. This choice is not the most suitable nursing diagnosis for a child with moderate anemia. While abnormal hemoglobin levels can affect cardiac output, moderate anemia typically doesn't lead to such a significant decrease in cardiac output that it becomes the primary nursing diagnosis. Activity intolerance is a more relevant concern.
Choice C rationale:
Activity intolerance related to generalized weakness. This is the most appropriate nursing diagnosis for a child diagnosed with moderate anemia. Moderate anemia results in a decrease in oxygen-carrying capacity, leading to generalized weakness and reduced ability to perform physical activities without becoming fatigued. The child's hemoglobin levels are likely low enough to cause noticeable activity intolerance.
Choice D rationale:
Risk for Injury related to dehydration and abnormal hemoglobin. This choice is not the best nursing diagnosis for a child with moderate anemia. Dehydration may exacerbate the effects of anemia, but the primary issue here is the anemia itself causing weakness and activity intolerance, which are better addressed with the choice C diagnosis.
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