An 18-month-old is brought to the emergency department with severe dehydration and weight loss secondary to acute diarrhea and vomiting. The nurse knows that therapeutic management of this child will begin with:
Administration of an anti-diarrheal
Clear liquids, 1 to 2 ounces at a time
Oral rehydration solution (ORS)
Intravenous fluids
The Correct Answer is C
Choice A reason: Administration of an anti-diarrheal is not the appropriate management for an 18-month-old with severe dehydration and weight loss secondary to acute diarrhea and vomiting. Anti-diarrheals are not recommended for children under 5 years, as they can have serious side effects, such as paralytic ileus, toxic megacolon, and worsening of dehydration. Anti-diarrheals do not address the underlying cause of diarrhea, and may prolong the duration of infection or toxin exposure.
Choice B reason: Clear liquids, 1 to 2 ounces at a time, are not sufficient to treat an 18-month-old with severe dehydration and weight loss secondary to acute diarrhea and vomiting. Clear liquids, such as water, tea, or broth, do not contain enough electrolytes, such as sodium, potassium, and bicarbonate, to replace the losses from diarrhea and vomiting. Clear liquids may also dilute the blood sodium level and cause hyponatremia, a condition of low sodium in the blood, which can lead to seizures, coma, and death.
Choice C reason: Oral rehydration solution (ORS) is the best management for an 18-month-old with severe dehydration and weight loss secondary to acute diarrhea and vomiting. ORS is a specially formulated solution that contains water, glucose, and electrolytes in the right proportions to replenish the fluid and electrolyte losses from diarrhea and vomiting. ORS can prevent or treat dehydration, and reduce the need for intravenous fluids. ORS can be given by mouth, spoon, cup, or syringe, depending on the child's ability to drink. The amount of ORS to give depends on the degree of dehydration and the weight of the child. The nurse should follow the guidelines from the World Health Organization (WHO) or the local health authority for the appropriate dosage and frequency of ORS administration¹.
Choice D reason: Intravenous fluids are not the first-line management for an 18-month-old with severe dehydration and weight loss secondary to acute diarrhea and vomiting. Intravenous fluids are only indicated for children who have severe dehydration and are unable to drink or tolerate ORS, or who have signs of shock, such as weak pulse, cold extremities, or altered consciousness. Intravenous fluids require hospitalization, skilled personnel, and sterile equipment, and carry the risk of infection, overhydration, or electrolyte imbalance. Intravenous fluids should be given according to the WHO or the local health authority guidelines, and should be switched to ORS as soon as the child is able to drink¹.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: I will always need to take hydrocortisone pills is a correct statement. Hydrocortisone is a synthetic form of cortisol, a hormone that is normally produced by the adrenal glands. After a bilateral adrenalectomy, the patient will have no adrenal glands and will need to take hydrocortisone pills for life to replace the missing hormone.
Choice B reason: I have a way to inject hydrocortisone in case of emergency is also a correct statement. Hydrocortisone injections are used to treat acute adrenal crisis, a life-threatening condition that can occur when the patient has low cortisol levels due to stress, illness, injury, or surgery. The patient should have an emergency kit with hydrocortisone injections and instructions on how to use them.
Choice C reason: I will stop taking hydrocortisone when I feel better is an incorrect statement. This indicates a need for further education regarding medications after a bilateral adrenalectomy. The patient should never stop taking hydrocortisone without consulting their doctor, as this can cause severe symptoms of adrenal insufficiency, such as low blood pressure, low blood sugar, weakness, fatigue, and confusion.
Choice D reason: I have nausea or vomiting often is a statement that requires further assessment by the nurse. Nausea or vomiting can be signs of inadequate or excessive hydrocortisone dosage, or other complications after a bilateral adrenalectomy. The nurse should monitor the patient's vital signs, blood glucose, electrolytes, and weight, and report any abnormal findings to the doctor. The patient may need to adjust their hydrocortisone dose or take other medications to manage their symptoms.
Correct Answer is C
Explanation
Choice A reason: This statement is false. A 12-month-old who is 2-days post-op cleft palate repair whose vital signs are within normal limits is not the priority for pain medication. This infant may have some pain from the surgery, but it is likely to be mild and manageable with non-pharmacological interventions, such as distraction, comfort, or oral care.
Choice B reason: This statement is false. A 6-month-old who is crying and becomes calm when held by a parent is not the priority for pain medication. This infant may have some pain from an unknown cause, but it is likely to be transient and responsive to non-pharmacological interventions, such as soothing, rocking, or cuddling.
Choice C reason: This statement is true. An 8-month-old with legs drawn to chest and a temperature of 39.5 degrees C is the priority for pain medication. This infant may have severe pain from an infection, such as appendicitis, meningitis, or urinary tract infection. This infant may also have signs of inflammation, such as fever, leukocytosis, or elevated C-reactive protein. This infant needs immediate pain relief and antibiotic therapy.
Choice D reason: This statement is false. A 4-month-old that has just returned from the recovery room is not the priority for pain medication. This infant may have some pain from the surgery, but it is likely to be moderate and controlled with pharmacological interventions, such as opioids, NSAIDs, or local anesthetics.
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