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
Rheumatic fever is often preceded by a streptococcal infection, such as strep throat. A sibling with a sore throat 3 weeks ago could have had a strep infection, which is a significant risk factor for developing rheumatic fever.
Choice B rationale
Chickenpox is caused by the varicella-zoster virus and is not related to rheumatic fever, which is a complication of streptococcal infections.
Choice C rationale
Gastritis is an inflammation of the stomach lining and is not associated with rheumatic fever.
Choice D rationale
Fifth disease is caused by parvovirus B19 and is not related to rheumatic fever.
Correct Answer is A
Explanation
Choice A rationale
Obtaining an influenza vaccine annually is crucial for individuals with type 1 diabetes mellitus. People with diabetes are at a higher risk of complications from infections, including influenza. The flu can lead to elevated blood sugar levels and potentially worsen diabetes control.
Therefore, getting the flu vaccine can help prevent or reduce the severity of the flu and its complications.
Choice B rationale
Administering glucagon is used for severe hypoglycemia, not hyperglycemia. Glucagon is a hormone that raises blood glucose levels by stimulating the liver to release stored glucose. It is typically used in emergency situations when a person with diabetes has very low blood sugar and is unable to consume sugar orally.
Choice C rationale
Insulin should be injected into subcutaneous tissue, not the deltoid muscle. The preferred injection sites for insulin are areas with more subcutaneous fat, such as the abdomen, thighs, buttocks, and upper arms. Injecting insulin into muscle tissue can lead to faster absorption and unpredictable blood glucose levels.
Choice D rationale
Glyburide is an oral medication used to treat type 2 diabetes, not type 1 diabetes. Type 1 diabetes requires insulin therapy because the body does not produce insulin. Glyburide works by stimulating the pancreas to release more insulin, which is not effective for individuals with type 1 diabetes who have little to no insulin production.