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
Tugging on the affected ear lobe is a common sign of otitis media in children. This behavior is often observed because the child is experiencing discomfort or pain in the ear, and tugging or pulling on the ear lobe is a way to express or alleviate that discomfort.
Choice B rationale
Erythema and edema of the affected ear are not typical findings in otitis media. These symptoms are more commonly associated with external ear infections, such as otitis externa.
Choice C rationale
Pain when manipulating the affected ear lobe is more indicative of otitis externa rather than otitis media. Otitis media involves the middle ear, and manipulation of the ear lobe does not typically cause pain.
Choice D rationale
Clear drainage from the affected ear is not a typical finding in otitis media. If there is drainage, it is usually purulent (pus-like) and indicates a more severe infection or a ruptured eardrum.
Correct Answer is B
Explanation
Choice A rationale
Encouraging deep breaths hourly can help prevent atelectasis and improve oxygenation, but it is not the priority in managing a vaso-occlusive crisis. The primary issue in a vaso-occlusive crisis is the blockage of blood flow due to sickled cells, leading to pain and potential organ damage. While deep breathing exercises are beneficial, they do not directly address the underlying cause of the crisis.
Choice B rationale
Maintaining fluids through an intravenous line is crucial in managing a vaso-occlusive crisis. Hydration helps to reduce blood viscosity, which can prevent further sickling of red blood cells and improve blood flow. Adequate hydration is essential to minimize the risk of complications such as stroke, acute chest syndrome, and organ damage. Therefore, maintaining IV fluids is a priority intervention in this scenario.
Choice C rationale
Beginning active range-of-motion exercises can help prevent joint stiffness and maintain mobility, but it is not the priority during an acute vaso-occlusive crisis. The primary focus should be on managing pain, ensuring adequate hydration, and preventing complications. Once the acute phase is managed, physical therapy and exercises can be introduced to support long- term health and mobility.
Choice D rationale
Seeing that the child ingests a protein-rich diet is important for overall health and growth, especially in children with chronic conditions like sickle cell anemia. However, during an acute vaso-occlusive crisis, the immediate priority is to manage pain, ensure hydration, and prevent complications. Nutritional support can be addressed once the acute crisis is under control.