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
Varying the child’s schedule each day can create a sense of unpredictability and insecurity. According to Erikson’s theory of psychosocial development, children in this age group (10 years old) are in the stage of industry versus inferiority. They need a sense of routine and structure to develop a sense of competence and accomplishment. A consistent schedule helps them feel secure and focused on their tasks.
Choice B rationale
Providing a daily session with a play therapist can be beneficial for the child’s emotional well- being. However, it does not directly address the child’s need for a sense of competence and accomplishment. According to Erikson’s theory, children in this age group need to develop a sense of industry by mastering tasks and completing school work.
Choice C rationale
Encouraging the client to complete school work helps promote a sense of industry and competence. According to Erikson’s theory, children in this age group need to develop a sense of accomplishment through mastering tasks. Completing school work provides them with a sense of purpose and achievement, which is essential for their psychosocial development.
Choice D rationale
Discouraging visits from the client’s friends can lead to feelings of isolation and loneliness. According to Erikson’s theory, social interactions and relationships are important for the child’s psychosocial development. Encouraging visits from friends can help the child feel connected and supported during their hospitalization.
Correct Answer is A
Explanation
Choice A rationale
Wilms tumor, also known as nephroblastoma, is a type of kidney cancer that primarily affects children. It is crucial not to palpate the abdomen of a child with a suspected Wilms tumor because this can cause the tumor to rupture and spread cancerous cells to other parts of the body.
Choice B rationale
This choice is incorrect because there is no specific restriction on venipuncture or blood pressure measurements in the left arm for children with Wilms tumor. This precaution is typically associated with conditions like lymphedema or after a mastectomy.
Choice C rationale
Collecting all urine is not a specific precaution for Wilms tumor. While monitoring urine output can be important in various conditions, it is not a primary concern for Wilms tumor.
Choice D rationale
Contact precautions are not necessary for Wilms tumor as it is not an infectious disease. Contact precautions are typically used for conditions that are contagious or spread through direct contact.