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. "The operation will straighten out the kink in the intestine.": Hirschsprung’s disease involves a lack of nerve cells in the colon, not a physical kink.
B. "I want to learn how to use the feeding tube as soon as possible.": Feeding tubes are not a standard part of treatment for Hirschsprung’s disease.
C. "I’m glad my child will have bowel movements now.": While the surgery will help bowel function, the initial goal is creating an ostomy to divert stool.
D. "I’m glad that the ostomy is only temporary.": The initial surgery often involves a temporary ostomy to allow the colon to heal before definitive repair.
Correct Answer is D
Explanation
A. Feed the infant half-strength formula for the first 48 hr: Feeding guidelines do not typically require diluted formula unless directed by the surgeon.
B. Remove elbow restraints while the infant is sleeping: Elbow restraints should remain in place to prevent the infant from touching the surgical site, even during sleep.
C. Administer pain medication PRN for the first 48 hr: Pain medication should be administered on a regular schedule initially to control pain effectively.
D. Keep the infant in a side-lying position: This position helps protect the surgical site and minimizes the risk of aspiration.
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