Which assessments are most relevant to the care of an infant with dehydration?
a. Temperature, heart rate, and blood pressure
b. Respiratory rate, oxygen saturation, and lung sounds
c. Heart rate, capillary refill, and skin color
d. Diet tolerance, bowel function, and abdominal girth
C
Changes in heart rate, capillary refill, and skin color are early indicators of impending shock in the child. Children can compensate and maintain an adequate cardiac output when they are hypovolemic. Blood pressure is not as reliable an indicator of shock as are changes in heart rate, sensorium, and skin color. Respiratory assessments will not provide data about impending hypovolemic shock. Diet tolerance, bowel function, and abdominal girth are not as important indicators of shock as heart rate, capillary refill, and skin color.
You might also like to view...
A patient has come into the free clinic for HIV testing. The test comes back positive and the patient is told they have HIV
While assessing the patient the nurse is aware that many patients with HIV utilize various alternative or complementary therapies. How does the nurse address complementary or alternative therapy? A) "Complementary therapies such as acupuncture or herbal therapy are dangerous to patients with HIV and we discourage you from exploring these types of therapy." B) "Researchers have not looked at the benefits of alternative therapy for patients with HIV, so we suggest that you stay away from these therapies until there is solid research data available." C) "We see many patients with HIV who are using some type of alternative therapy and there are benefits and risks. Are there any types of alternative or complementary therapies that you follow or are there any herbs that you take?" D) "You do not take herbs or practice some type of alternative medicine such as acupuncture, message therapy, hypnosis or diet therapy, do you?"
A client with advanced cancer is being treated with intravenous mithramycin (Mithracin). Which clinical manifestation indicates that the treatment is effective?
a. Bowel sounds are active in all four qua-drants. b. The client's serum sodium level is 138 mEq/L. c. The pulse rate is 68 beats/min and bound-ing. d. Urine output has increased to 30 mL/hr.
Based on the most frequent cause of death in adolescents, what preventive measure would you most want to teach an adolescent?
A) Home safety B) Motor-vehicle safety C) Firearm safety D) Water safety
A teenage boy has been periodically beaten by his father. The boy tells the nurse, "He'll pay for this one way or another." The nurse treating his contusions should assess for behaviors suggest-ing:
1. Antisocial tendencies 2. Depression 3. Regression 4. Withdrawal