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Exhibits

The nurse reviews the intake information prior to seeing the client.

What finding(s) should the nurse recognize as signs of dehydration that require immediate follow up? Select all that apply.

Temperature 99.9° F (37.7° C)

Respirations 34 breaths/minute

Heart rate 136 beats/minute

Weak peripheral pulses

Dry mucous membranes

Body mass index (BMI) 21.9 kg/m2

Blood pressure 100/52 mm Hg

Poor skin turgor

Answer and Explanation

Correct Answer : C,D,E,G,H

A. Temperature 99.9° F (37.7° C): A mild fever (99.9°F) is not a direct indicator of dehydration but could be related to other factors, including the body’s response to stress. It is not an immediate priority compared to other signs like poor skin turgor or low blood pressure.

B. Respirations 34 breaths/minute: An elevated respiratory rate may occur with dehydration, but it is not specific to dehydration alone. It should be monitored, especially when combined with other symptoms, but it is not a sole indicator of dehydration.

C. Heart rate 136 beats/minute: A heart rate of 136 beats per minute is elevated and may indicate dehydration, as the body attempts to compensate for reduced blood volume. Tachycardia is a common response to fluid loss and requires immediate follow-up.

D. Weak peripheral pulses: Weak peripheral pulses reflect poor circulation, which can be a result of dehydration. This finding indicates decreased perfusion and demands urgent attention to restore fluid balance and ensure proper circulation.

E. Dry mucous membranes: Dry mucous membranes are a hallmark sign of dehydration, as the body reduces fluid availability for non-essential processes. This finding should be immediately addressed, as it is a clear sign of fluid loss.

F. Body mass index (BMI) 21.9 kg/m²: BMI is a general indicator of body weight and is not related to fluid balance. While it provides useful information about the client’s overall health, it does not directly point to dehydration or fluid loss.

G. Blood pressure 100/52 mm Hg: Low blood pressure, especially in the context of dehydration, is a significant concern. A blood pressure of 100/52 mm Hg is a sign of hypovolemia or fluid loss, and immediate intervention is needed to restore normal fluid volume and prevent shock.

H. Poor skin turgor: Poor skin turgor is a classic sign of dehydration, where the skin remains tented after being pinched. This indicates a lack of sufficient fluid in the body, which must be addressed immediately to prevent further complications.

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Correct Answer is ["B","C","E"]

Explanation

A. Explain expected side effects of postoperative chemotherapy: Chemotherapy and its side effects are typically discussed after surgery when the treatment plan is clearer. The focus before surgery should be on preparing the child and family for the surgery itself.

B. Monitor blood pressure every 2 hours for hypertension: Wilm's tumor can be associated with hypertension due to renin production from the tumor, so monitoring the child's blood pressure closely is essential to detect any signs of hypertension early.

C. Provide parents with simple explanations and repeat often: Simplified, repeated explanations are key to helping parents understand the diagnosis and surgical procedure. This approach supports emotional comfort and ensures informed decision-making.

D. Attend all healthcare provider and parent conferences: While it is important to support the family, the nurse’s role in attending all healthcare provider and parent conferences is not mandatory unless specifically needed for continuity of care.

E. Measure the child's abdominal girth: Measuring abdominal girth is essential preoperatively to monitor for any abdominal changes, such as swelling or distension, which could indicate tumor growth or other complications related to the Wilm's tumor.

A. Dilated pupils, tachycardia, elevated blood pressure, elation. B. Excessive eating, constipation, headache. C. Nausea, vomiting, diaphoresis, anxiety, tremors. D. Mood lability, poor hand coordination, fever, drowsiness.

Correct Answer is C

Explanation

A. Dilated pupils, tachycardia, elevated blood pressure, elation: These symptoms are more typical of stimulant intoxication and do not indicate alcohol withdrawal. They are not consistent with the need for a detox protocol focused on alcohol or other depressants.

B. Excessive eating, constipation, headache: These symptoms are not associated with alcohol or drug intoxication or withdrawal. They do not suggest a need for detoxification medication protocols.

C. Nausea, vomiting, diaphoresis, anxiety, tremors: These are classic signs of alcohol withdrawal and suggest the need for detoxification. These symptoms require immediate intervention to manage withdrawal safely and avoid complications.

D. Mood lability, poor hand coordination, fever, drowsiness: These signs are more indicative of intoxication with substances like sedatives. While concerning, they do not point to alcohol withdrawal, which requires specific detox protocols.

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Exhibits The nurse reviews the intake information prior to seeing the client. What finding(s) should the nurse recognize as signs of dehydration that require immediate follow up? Select all that apply.

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A 3-year-old child is admitted with a Stage II Wilm's tumor. Which preoperative intervention(s) should the nurse implement? Choose all that apply.

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Explanation

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Correct Answer is C

Explanation

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Exhibits

The nurse reviews the intake information prior to seeing the client.

What finding(s) should the nurse recognize as signs of dehydration that require immediate follow up? Select all that apply.