A nurse in an emergency department is caring for an infant who has a 2-day history of vomiting and an elevated temperature. Which of the following should the nurse recognize as the most reliable indicator of fluid loss?
Blood pressure.
Respiratory rate.
Body weight.
Skin integrity.
The Correct Answer is C
Choice A rationale
Blood pressure is not the most reliable indicator of fluid loss in infants. Blood pressure can remain normal until dehydration is severe.
Choice B rationale
Respiratory rate can be affected by many factors and is not the most reliable indicator of fluid loss.
Choice C rationale
Body weight is the most reliable indicator of fluid loss in infants. A significant decrease in body weight indicates significant fluid loss and helps guide appropriate fluid replacement therapy.
Choice D rationale
Skin integrity can be affected by many factors and is not the most reliable indicator of fluid loss.
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Correct Answer is A
Explanation
Choice A rationale
Ignoring temper tantrums is an effective strategy for managing this behavior. By not giving attention to the tantrum, the child learns that this behavior will not achieve the desired outcome. This approach helps reduce the frequency and intensity of tantrums over time.
Choice B rationale
Restraining the child physically during a temper tantrum can escalate the situation and may cause injury to the child or the caregiver. It is not recommended as a strategy for managing temper tantrums.
Choice C rationale
Distracting the child by offering to play a game can be an effective strategy for preventing tantrums, but it is not the best approach once a tantrum has already started. Ignoring the tantrum is more effective in reducing the behavior over time.
Choice D rationale
Telling the child that temper tantrums are not acceptable may not be effective during the tantrum itself. The child is unlikely to be receptive to verbal reasoning during a tantrum. Ignoring the tantrum is a more effective strategy.
Correct Answer is C
Explanation
Choice A rationale
Coughing and shortness of breath in the morning are signs of poor asthma control, not well- controlled asthma. These symptoms indicate that the child’s asthma is not being managed effectively and may require adjustments in their treatment plan.
Choice B rationale
This statement is incorrect. If asthma is not controlled, the child is likely to miss more days of school due to asthma symptoms and exacerbations. Effective asthma management aims to reduce symptoms and prevent asthma attacks, allowing the child to attend school regularly.
Choice C rationale
Eliminating allergens that irritate the lungs is a key strategy in preventing asthma attacks. Allergens such as dust mites, pet dander, mold, and pollen can trigger asthma symptoms. By reducing exposure to these allergens, the child can better manage their asthma and reduce the frequency of attacks.
Choice D rationale
This statement is false. Children with well-controlled asthma can participate in sports and physical activities. Physical activity is beneficial for lung function and overall health. The nurse should teach the child how to prevent exercise-induced asthma symptoms, such as using a bronchodilator before exercise.