A clinic nurse is caring for a 4-year-old client with acute diarrhea and mild dehydration who is afebrile, active, and alert. The nurse is providing instructions to the parent. Which statement by the parent indicates understanding?
"We can anticipate needing intravenous fluids to correct the dehydration."
"I will continue to give oral rehydration in small amounts."
"Chicken broth will replace the needed electrolytes lost."
"If my child's soft spot becomes depressed, I will notify the healthcare provider immediately."
The Correct Answer is B
Rationale:
A. Intravenous fluids are generally not required if the child is alert and active with mild dehydration; oral rehydration is usually sufficient.
B. Oral rehydration solutions are appropriate for treating mild dehydration and should be given in small amounts frequently.
C. Chicken broth is not ideal for replacing electrolytes because it is low in electrolytes and high in sodium. Oral rehydration solutions are preferred.
D. A depressed soft spot (fontanel) is a sign of severe dehydration in infants. For a 4-year-old, signs of dehydration would include changes in urine output, thirst, or dry mucous membranes rather than a depressed fontanel.
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Correct Answer is A
Explanation
Rationale:
A. Hypertension (blood pressure of 136/92 mm Hg) in a child with acute pyelonephritis can indicate a severe condition that may lead to renal damage or worsening kidney function. Immediate intervention is necessary to manage high blood pressure and prevent complications.
B. A heart rate of 100 bpm is within normal limits for a 7-year-old and does not require immediate action.
C. Decreased urine output is concerning and needs monitoring, but hypertension is the more urgent issue.
D. Tea-colored urine suggests hematuria or concentrated urine, which is important but not as immediately life-threatening as high blood pressure.
Correct Answer is A
Explanation
Rationale:
A. Projectile vomiting is a classic sign of pyloric stenosis, where the thickened pylorus muscle obstructs the passage of food from the stomach to the small intestine, causing forceful vomiting.
B. Large amounts of bilious emesis would suggest an obstruction beyond the pylorus, which is not characteristic of pyloric stenosis.
C. Watery diarrhea is not associated with pyloric stenosis, which typically causes dehydration and constipation.
D. Steatorrhea, or fatty stools, is not a feature of pyloric stenosis but rather is associated with malabsorption syndromes.