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
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
Correct Answer is B
Explanation
Choice A rationale
Treating upper respiratory infections with over-the-counter medication is not recommended for children with sickle cell anemia. These children are at higher risk for infections and complications, and any signs of infection should be promptly evaluated by a healthcare provider.
Choice B rationale
Ensuring a consistent and daily intake of adequate fluids is crucial for preventing dehydration in children with sickle cell anemia. Dehydration can trigger a sickle cell crisis, leading to severe pain and other complications.
Choice C rationale
Avoiding immunizations is incorrect. Children with sickle cell anemia should receive all recommended vaccinations to prevent infections, which can be more severe in these children.
Choice D rationale
Suggesting that the child participate in sports activities without restriction is not advisable. Children with sickle cell anemia should avoid strenuous activities that can lead to dehydration and trigger a sickle cell crisis. .