The nurse is monitoring for signs and symptoms of dehydration in a 1 year old child who has been hospitalized for diarrhea and prepares to take the child's temperature. Which method of temperature measurement should be avoided?
Orally
Tympanic
Rectal
Axillary
The Correct Answer is C
A. Orally: Oral temperature measurement is generally not suitable for a 1-year-old because they are often not able to cooperate, but it is not contraindicated for the child.
B. Tympanic: Tympanic (ear) temperature measurement is acceptable in children over 3 months old and is non-invasive.
C. Rectal: Rectal temperature should be avoided in infants and toddlers with diarrhea due to the risk of rectal trauma and infection. Diarrhea may also cause irritation to the rectal area, increasing the risk of injury.
D. Axillary: Axillary (underarm) temperature measurement is safe and commonly used in children, particularly for non-invasive monitoring.
Nursing Test Bank
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Related Questions
Correct Answer is D
Explanation
A. Wrist: Wrist restraints do not prevent the infant from touching their mouth.
B. Mummy: A mummy restraint immobilizes the entire body, which is unnecessary and can cause distress.
C. Jacket: Jacket restraints are not appropriate or indicated for postoperative care of cleft lip and palate.
D. Elbow: Elbow restraints prevent the infant from bending their arms and touching or disrupting the surgical repair site.
Correct Answer is B
Explanation
A. Poor appetite: Poor appetite is a common symptom in nephrotic syndrome but is not immediately life-threatening or an urgent concern.
B. Facial edema: This can indicate worsening fluid retention or disease progression, requiring immediate evaluation and possible adjustment in treatment.
C. Yellow nasal discharge: This likely indicates a mild upper respiratory infection, which is not directly related to nephrotic syndrome.
D. Irritability: Irritability is non-specific and can occur in various pediatric illnesses but is not an urgent manifestation.
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