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 D
Explanation
Choice A rationale
Encouraging progressive activity is generally beneficial for children with various health conditions, but it is not the primary focus for a child with polycythemia caused by a congenital heart disorder. The main concern is managing the increased blood viscosity and preventing complications related to it.
Choice B rationale
Expecting the skin to turn yellow is not a typical symptom of polycythemia. Jaundice is more commonly associated with liver conditions or hemolytic diseases, not polycythemia caused by congenital heart disorders.
Choice C rationale
Preparing for seizures is not directly related to polycythemia. Seizures are more commonly associated with neurological conditions or severe electrolyte imbalances, not polycythemia.
Choice D rationale
Preventing dehydration is crucial for children with polycythemia because dehydration can increase blood viscosity, leading to a higher risk of thrombotic events. Ensuring adequate hydration helps maintain proper blood flow and reduces the risk of complications.
Correct Answer is B
Explanation
Choice A rationale
Encouraging regular activity level as soon as possible is not appropriate for a child with streptococcal pharyngitis. Rest is important to allow the body to recover and prevent complications.
Choice B rationale
Completing the entire course of antibiotics is crucial to prevent complications such as rheumatic fever, which can result from untreated or partially treated streptococcal infections.
Choice C rationale
Expecting the lymph nodes to swell and obstruct the airway is not a typical outcome of streptococcal pharyngitis. While lymph node swelling can occur, it usually does not obstruct the airway.
Choice D rationale
Being aware that the infection may spread and cause a tooth abscess is not a common complication of streptococcal pharyngitis. The primary concern is preventing complications like rheumatic fever and ensuring complete recovery.