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 C
Explanation
Choice A rationale
Placing the child on a no-salt-added diet is important for managing fluid retention and hypertension in acute glomerulonephritis, but it is not the immediate priority.
Choice B rationale
Educating the parents about potential complications is essential for long-term management, but it is not the immediate priority in an acute setting.
Choice C rationale
Checking the child’s daily weight is the priority action because it helps monitor fluid balance and detect any signs of fluid retention or worsening condition. Accurate daily weight measurements are crucial for assessing the effectiveness of treatment and making necessary adjustments.
Choice D rationale
Maintaining a saline-lock is important for intravenous access, but it is not the immediate priority compared to monitoring fluid balance through daily weight checks.
Correct Answer is B
Explanation
Choice A rationale
Environment plays a significant role in a child’s growth and development, including factors like socioeconomic status, access to education, and living conditions. However, it can be altered to some extent.
Choice B rationale
Genetics is the largest factor impacting growth and development that cannot be altered. Genetic factors determine physical characteristics, susceptibility to certain diseases, and overall growth patterns.
Choice C rationale
Socialization influences a child’s development, including social skills and behavior. While important, it can be influenced and altered through various interventions.
Choice D rationale
Nutrition is crucial for growth and development, affecting physical and cognitive development. However, it can be modified through dietary changes and interventions.