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 B
Explanation
Choice A rationale
Administering an oral analgesic does not aid in bronchodilation and is not effective in treating laryngotracheobronchitis (Croup)10.
Choice B rationale
Assisting with racemic epinephrine nebulizer therapy is the most effective measure in aiding bronchodilation in a child with laryngotracheobronchitis (Croup). Racemic epinephrine helps reduce airway swelling and improve breathing.
Choice C rationale
Urging the child to continue to take oral fluids is important for hydration but does not directly aid in bronchodilation.
Choice D rationale
Teaching the child to take long, slow breaths can help with breathing techniques but is not the most effective measure for bronchodilation.
Correct Answer is C
Explanation
Choice A rationale
Puberty might be delayed if scrotal changes have not occurred by the age of 13½ to 14 years, not 11 years.
Choice B rationale
Changes in the voice occur during puberty but do not signal its beginning. Enlargement of the testicles is the first sign of puberty in boys.
Choice C rationale
Growth spurts in height typically occur toward the end of mid-puberty, making this the correct answer.
Choice D rationale
Gynecomastia, or the development of breast tissue in boys, commonly occurs during mid- puberty, not late puberty