Week 7
Which assessment would be the most accurate method of monitoring the hydration status of a 2-month-old infant admitted with diarrhea and dehydration?
Obtaining daily weights Daily weighing provides an objective measurement, because a weight loss indicates a loss of fluid; approximately 1 kg (2.2 lb) is equal to 1 L of fluid. Although a wet diaper count is an objective measure, it is necessary to weigh the diapers before and after the infant voids to estimate the amount of fluid loss. Intake can be measured accurately; however, output, especially with diarrhea, is difficult to measure. Tissue turgor is a subjective assessment, open to a variety of interpretations. Also, the site that should be assessed is over the sternum, not the abdomen.
Which intervention would be included in the plan of care for a child with nephrotic syndrome?
Providing meticulous skin care Massive edema, typical of nephrotic syndrome, predisposes the child to skin breakdown. The child requires more fluid than 4 oz (120 mL) each shift to maintain hydration. Carbohydrates and proteins are not restricted. Children with nephrotic syndrome usually do not receive blood transfusions. View Topics
Heart failure develops in a 4-month-old infant with a congenital heart defect, and the infant exhibits marked dyspnea at rest. Which assessment finding would the nurse expect in this infant?
Bilateral crackles The increased blood volume and pressure in the lungs from impaired myocardial function result in pulmonary edema, which causes dyspnea; it is a sign of heart failure. Oxygenation is a priority concern that should be addressed immediately. Polycythemia, not anemia, is more common, because red blood cell production is increased to counteract hypoxia. Hypervolemia, not hypovolemia, is related to heart failure and pulmonary edema. Respiratory, not metabolic, acidosis can develop because of pulmonary insufficiency, resulting in retention of carbon dioxide.
A child with sickle cell anemia is admitted to the pediatric unit in a vasoocclusive crisis. Which interventions would be implemented after the pain is under control? Select all that apply. One, some, or all responses may be correct.
-Rehydration -Oxygen (O 2) therapy During a sickle cell crisis the red blood cells are sickled and interfere with the peripheral vascular circulation; fluids are needed to increase the circulating volume. Supplemental O 2 is beneficial to limit sickling. There is no indication of an infection that requires antibiotic therapy. There is no indication that the child is malnourished. Although counseling may be needed in the future, there is no indication that it is needed at this time.
The nurse is performing an assessment on a child who has been admitted to the hospital with the diagnosis of acute lymphocytic leukemia (ALL). Which early clinical findings would the nurse expect to identify?
Fatigue and ecchymotic areas Fatigue and ecchymoses are early clinical findings to ALL. They are caused by decreased white blood cell, red blood cell (RBC), and platelet production that results when the bone marrow is crowded with abnormal lymph cells. Although epistaxis does occur, papilledema is not a common presenting sign because the blood-brain barrier is an initial deterrent. Pain is not an early symptom of ALL. The skin will be pale, not reddened, because of a decreased RBC count. Enlargement of lymph nodes in the axillae and groin is a sign of lymphoma or a late, not early, sign of leukemia.
