PEDS Chapter 23: The Child with Fluid and Electrolyte Imbalance

Nurses should be alert for increased fluid requirements in which circumstance? a. Fever b. Mechanical ventilation c. Congestive heart failure d. Increased intracranial pressure

A Fever leads to great insensible fluid loss in young children because of increased body surface area relative to fluid volume. The mechanically ventilated child has decreased fluid requirements. Congestive heart failure is a case of fluid overload in children. Increased intracranial pressure does not lead to increased fluid requirements in children.

A 7-year-old child with acute diarrhea has been rehydrated with oral rehydration solution (ORS). The nurse should recommend that the child's diet be advanced to what kind of diet? a. Regular diet b. Clear liquids c. High carbohydrate diet d. BRAT (bananas, rice, applesauce, and toast or tea) diet

A It is appropriate to advance to a regular diet after ORS has been used to rehydrate the child. Clear liquids are not appropriate for hydration or afterward. A high carbohydrate diet may contribute to loose stools because of the low electrolyte content and high osmolality. The BRAT diet has little nutritional value and is high in carbohydrates.

What is the required number of milliliters of fluid needed per day for a 14-kg child? a. 800 b. 1000 c. 1200 d. 1400

C For the first 10 kg of body weight, a child requires 100 ml/kg. For each additional kilogram of body weight, an extra 50 ml is needed. 10 kg x 100 ml/kg/day = 1000 ml 4 kg x 50 ml/kg/day = 200 ml 1000 ml + 200 ml = 1200 ml/day Eight hundred to 1000 ml is too little; 1400 ml is too much.

What organism is a parasite that causes acute diarrhea? a. Shigella organisms b. Salmonella organisms c. Giardia lamblia d. Escherichia coli

C G. lamblia is a parasite that represents 10% of nondysenteric illness in the United States. Shigella, Salmonella, and E. coli are bacterial pathogens.

What condition is often associated with severe diarrhea? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

A Metabolic acidosis results from the increased absorption of short-chain fatty acids produced in the colon. There is an increase in lactic acid from tissue hypoxia secondary to hypovolemia. Bicarbonate is lost through the stool. Ketosis results from fat metabolism when glycogen stores are depleted. Metabolic alkalosis and respiratory alkalosis do not occur from severe diarrhea.

Ongoing fluid losses can overwhelm the child's ability to compensate, resulting in shock. What early clinical sign precedes shock? a. Tachycardia b. Slow respirations c. Warm, flushed skin d. Decreased blood pressure

A Shock is preceded by tachycardia and signs of poor tissue perfusion and decreased pulse oximetry values. Respirations are increased as the child attempts to compensate. As a result of the poor peripheral circulation, the child has skin that is cool and mottled with decreased capillary refilling after blanching. In children, lowered blood pressure is a late sign and may accompany the onset of cardiovascular collapse.

What laboratory finding should the nurse expect in a child with an excess of water? a. Decreased hematocrit b. High serum osmolality c. High urine specific gravity d. Increased blood urea nitrogen

A The excess water in the circulatory system results in hemodilution. The laboratory results show a falsely decreased hematocrit. Laboratory analysis of blood that is hemodiluted reveals decreased serum osmolality and blood urea nitrogen. The urine specific gravity is variable relative to the child's ability to correct the fluid imbalance.

In what condition should the nurse be alert for altered fluid requirements in children? (Select all that apply.) a. Oliguric renal failure b. Increased intracranial pressure c. Mechanical ventilation d. Compensated hypotension e. Tetralogy of Fallot f. Type 1 diabetes mellitus

A, B, C The nurse should recognize that conditions such as oliguric renal failure, increased intracranial pressure, and mechanical ventilation can cause an increase or a decrease in fluid requirements. Conditions such as hypotension, tetralogy of Fallot, and diabetes mellitus (type 1) do not cause an alteration in fluid requirements.

The nurse suspects fluid overload in an infant receiving intravenous fluids. What clinical manifestation is suggestive of water intoxication? a. Oliguria b. Weight loss c. Irritability and seizures d. Muscle weakness and cardiac dysrhythmias

C Irritability, somnolence, headache, vomiting, diarrhea, and generalized seizures are manifestations of water intoxication. Urinary output is increased as the child attempts to maintain fluid balance. Weight gain is usually associated with water intoxication. Muscle weakness and cardiac dysrhythmias are not associated with water intoxication.

What type of dehydration occurs when the electrolyte deficit exceeds the water deficit? a. Isotonic dehydration b. Hypotonic dehydration c. Hypertonic dehydration d. Hyperosmotic dehydration

B Hypotonic dehydration occurs when the electrolyte deficit exceeds the water deficit, leaving the serum hypotonic. Isotonic dehydration occurs in conditions in which electrolyte and water deficits are present in balanced proportion. Hypertonic dehydration results from water loss in excess of electrolyte loss. This is the most dangerous type of dehydration. It is caused by feeding children fluids with high amounts of solute. Hyperosmotic dehydration is another term for hypertonic dehydration.

What amount of fluid loss occurs with moderate dehydration? a. <50 ml/kg b. 50 to 90 ml/kg c. <5% total body weight d. >15% total body weight

B Moderate dehydration is defined as a fluid loss of between 50 and 90 ml/kg. Mild dehydration is defined as a fluid loss of less than 50 ml/kg. Weight loss up to 5% is considered mild dehydration. Weight loss over 15% is severe dehydration.

The nurse is caring for an 18-month-old child with rotavirus. What clinical manifestations should the nurse expect to observe? a. Severe abdominal cramping and bloody diarrhea b. Mild fever and vomiting followed by onset of watery stools c. Colicky abdominal pain and vomiting d. High fever, diarrhea, and lethargy

B Rotavirus is one of the most common pathogens that cause gastroenteritis in children younger than the age of 2 years. Clinical manifestations include mild to moderate fever and vomiting followed by the onset of watery stools. The fever and vomiting usually abate in 1 or 2 days, but the diarrhea persists for 5 to 7 days. Severe abdominal cramping and bloody diarrhea are seen with Escherichia coli infection; colicky abdominal pain and vomiting are seen with salmonella infection; and high fever, diarrhea, and lethargy are seen with infection by Salmonella typhi.

What is an approximate method of estimating output for a child who is not toilet trained? a. Have parents estimate output. b. Weigh diapers after each void. c. Place a urine collection device on the child. d. Have the child sit on a potty chair 30 minutes after eating.

B Weighing diapers will provide an estimate of urinary output. Each 1 g of weight is equivalent to 1 ml of urine. Having parents estimate output would be inaccurate. It is difficult to estimate how much fluid is in a diaper. The urine collection device would irritate the child's skin. It would be difficult for a toddler who is not toilet trained to sit on a potty chair 30 minutes after eating.

What clinical manifestations should be observed in a 2-year-old child with hypotonic dehydration? (Select all that apply.) a. Thick, doughy feel to the skin b. Slightly moist mucous membranes c. Absent tears d. Very rapid pulse e. Hyperirritability

B, C, D Clinical manifestations of hypotonic dehydration include slightly moist mucous membranes, absent tears, and a very rapid pulse. A thick, doughy feel to the skin and hyperirritability are signs of hypertonic dehydration

The nurse is caring for a child with hypercalcemia. The nurse evaluates the child for which signs and symptoms of hypercalcemia? (Select all that apply.) a. Tetany b. Anorexia c. Constipation d. Laryngospasm e. Muscle hypotonicity

B, C, E Signs and symptoms of hypercalcemia are anorexia, constipation, and muscle hypotonicity. Tetany and laryngospasm are signs of hypocalcemia.

The nurse is caring for a child with hypernatremia. The nurse evaluates the child for which signs and symptoms of hypernatremia? (Select all that apply.) a. Apathy b. Lethargy c. Oliguria d. Intense thirst e. Dry, sticky mucos

B, C, E Signs and symptoms of hypernatremia are nausea; oliguria; and dry, sticky mucos. Apathy and lethargy are signs of hyponatremia

The nurse is caring for a child with hypokalemia. The nurse evaluates the child for which signs and symptoms of hypokalemia? (Select all that apply.) a. Twitching b. Hypotension c. Hyperreflexia d. Muscle weakness e. Cardiac arrhythmias

B, D, E Signs and symptoms of hypokalemia are hypotension, muscle weakness, and cardiac arrhythmias. Twitching and hyperreflexia are signs of hyperkalemia.

A school-age child with acute diarrhea and mild dehydration is being given oral rehydration solutions (ORS). The child's mother calls the clinic nurse because he is also occasionally vomiting. The nurse should recommend which intervention? a. Bring the child to the hospital for intravenous fluids. b. Alternate giving ORS and carbonated drinks. c. Continue to give ORS frequently in small amounts. d. Keep child NPO (nothing by mouth) for 8 hours and resume ORS if vomiting has subsided.

C Children who are vomiting should be given ORS at frequent intervals and in small amounts. Intravenous fluids are not indicated for mild dehydration. Carbonated beverages are high in carbohydrates and are not recommended for the treatment of diarrhea and vomiting. The child is not kept NPO because this would cause additional fluid losses.

Physiologically, the child compensates for fluid volume losses by which mechanism? a. Inhibition of aldosterone secretion b. Hemoconcentration to reduce cardiac workload c. Fluid shift from interstitial space to intravascular space d. Vasodilation of peripheral arterioles to increase perfusion

C Compensatory mechanisms attempt to maintain fluid volume. Initially, interstitial fluid moves into the intravascular compartment to maintain blood volume. Aldosterone is released to promote sodium retention and conserve water in the kidneys. Hemoconcentration results from the fluid volume loss. With less circulating volume, tachycardia results. Vasoconstriction of peripheral arterioles occurs to help maintain blood pressure.

The nurse is teaching a group of female adolescents about toxic shock syndrome and the use of tampons. What statement by a participant indicates a need for additional teaching? a. "I can alternate using a tampon and a sanitary napkin." b. "I should wash my hands before inserting a tampon." c. "I can use a superabsorbent tampon for more than 6 hours." d. "I should call my health care provider if I suddenly develop a rash that looks like sunburn."

C Teaching female adolescents about the association between toxic shock syndrome and the use of tampons is important. The teaching should include not using superabsorbent tampons; not leaving the tampon in for longer than 4 to 6 hours; alternating the use of tampons with sanitary napkins; washing hands before inserting a tampon to decrease the chance of introducing pathogens; and informing a health care provider if a sudden high fever, vomiting, muscle pain, dizziness, or a rash that looks like a sunburn appears.

What factor predisposes an infant to fluid imbalances? a. Decreased surface area b. Lower metabolic rate c. Immature kidney functioning d. Decreased daily exchange of extracellular fluid

C The infant's kidneys are functionally immature at birth and are inefficient in excreting waste products of metabolism. Infants have a relatively high body surface area (BSA) compared with adults. This allows a higher loss of fluid to the environment. A higher metabolic rate is present as a result of the higher BSA in relation to active metabolic tissue. The higher metabolic rate increases heat production, which results in greater insensible water loss. Infants have a greater exchange of extracellular fluid, leaving them with a reduced fluid reserve in conditions of dehydration.

An infant is brought to the emergency department with the following clinical manifestations: poor skin turgor, weight loss, lethargy, tachycardia, and tachypnea. This is suggestive of which situation? a. Water excess b. Sodium excess c. Water depletion d. Potassium excess

C These clinical manifestations indicate water depletion or dehydration. Edema and weight gain occur with water excess or overhydration. Sodium or potassium excess would not cause these symptoms.

The presence of which pair of factors is a good predictor of a fluid deficit of at least 5% in an infant? a. Weight loss and decreased heart rate b. Capillary refill of less than 2 seconds and no tears c. Increased skin elasticity and sunken anterior fontanel d. Dry mucous membranes and generally ill appearance

D A good predictor of a fluid deficit of at least 5% is any two four factors: capillary refill of more than 2 seconds, absent tears, dry mucous membranes, and ill general appearance. Weight loss is associated with fluid deficit, but the degree needs to be quantified. Heart rate is usually elevated. Skin elasticity is decreased, not increased. The anterior fontanel is depressed.

Clinical manifestations of sodium excess (hypernatremia) include which signs or symptoms? a. Hyperreflexia b. Abdominal cramps c. Cardiac dysrhythmias d. Dry, sticky mucous membranes

D Dry, sticky mucous membranes are associated with hypernatremia. Hyperreflexia is associated with hyperkalemia. Abdominal cramps, weakness, dizziness, nausea, and apprehension are associated hyponatremia. Cardiac dysrhythmias are associated with hypokalemia.

A school-age child with diarrhea has been rehydrated. The nurse is discussing the child's diet with the family. What food or beverage should be tolerated best? a. Clear fluids b. Carbonated drinks c. Applesauce and milk d. Easily digested foods

D Easily digested foods such as cereals, cooked vegetables, and meats should be provided for the child. Early reintroduction of nutrients is desirable. Continued feeding or reintroduction of a regular diet has no adverse effects and actually lessens the severity and duration of the illness. Clear fluids (e.g., fruit juices and gelatin) and carbonated drinks have high carbohydrate content and few electrolytes. Caffeinated beverages should be avoided because caffeine is a mild diuretic. In some children, lactose intolerance will develop with diarrhea, and cow's milk should be avoided in the recovery stage.

What clinical manifestation(s) is associated with calcium depletion (hypocalcemia)? a. Nausea, vomiting b. Weakness, fatigue c. Muscle hypotonicity d. Neuromuscular irritability

D Neuromuscular irritability is a clinical manifestation of hypocalcemia. Nausea and vomiting occur with hypercalcemia and hypernatremia. Weakness, fatigue, and muscle hypotonicity are clinical manifestations of hypercalcemia.

What finding is the most reliable guide to the adequacy of fluid replacement for a small child with burns? a. Absence of thirst b. Falling hematocrit c. Increased seepage from burn wound d. Urinary output of 1 to 2 ml/kg of body weight/hr

D Replacement fluid therapy is delivered to provide a urinary output of 30 ml/hr in older children or 1 to 2 ml/kg of body weight/hr for children weighing less than 30 kg (66 lb). Thirst is the result of a complex set of interactions and is not a reliable indicator of hydration. Thirst occurs late in dehydration. A falling hematocrit would be indicative of hemodilution. This may reflect fluid shifts and may not accurately represent fluid replacement therapy. Increased seepage from a burn wound would be indicative of increased output, not adequate hydration.

What physiologic state(s) produces the clinical manifestations of nervous system stimulation and excitement, such as overexcitability, nervousness, and tetany? a. Metabolic acidosis b. Respiratory alkalosis c. Metabolic and respiratory acidosis d. Metabolic and respiratory alkalosis

D The major symptoms and signs of alkalosis include nervous system stimulation and excitement, including overexcitability, nervousness, tingling sensations, and tetany that may progress to seizures. Acidosis (both metabolic and respiratory) has clinical signs of depression of the central nervous system, such as lethargy, diminished mental capacity, delirium, stupor, and coma. Respiratory alkalosis has the same symptoms and signs as metabolic alkalosis.