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
Over-riding suture lines are not a typical manifestation of hydrocephalus. This condition involves the accumulation of cerebrospinal fluid within the brain’s ventricles, leading to increased intracranial pressure.
Choice B rationale
A backward sloping appearance of the forehead is not associated with hydrocephalus. This condition typically presents with an enlarged head circumference due to fluid accumulation.
Choice C rationale
Dilated scalp veins are a common manifestation of hydrocephalus. The increased intracranial pressure causes the veins to become more prominent and visible.
Choice D rationale
Hypertension is not a primary symptom of hydrocephalus in newborns. The condition primarily affects the brain and skull, leading to symptoms like an enlarged head, bulging fontanelles, and dilated scalp veins.
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.