A nurse is caring for a child with dehydration. The nurse should monitor for which of the following signs or symptoms as an indication of severe dehydration?

Correct Answer: D

Rationale: In caring for a child with dehydration, monitoring for signs and symptoms of severe dehydration is crucial for timely intervention. The correct answer is option D, "Sunken fontanels." Fontanels are soft spots on a baby's head where the skull bones have not yet fused. Sunken fontanels are a significant sign of severe dehydration in infants and young children as they indicate a significant decrease in fluid volume in the body. Option A, "Dry mouth and tongue," can be seen in moderate dehydration but may not necessarily indicate severe dehydration. Option B, "Reduced urine output," is a sign of dehydration but may not specifically indicate severe dehydration unless it is accompanied by other severe symptoms. Option C, "Rapid breathing," can be a response to dehydration, but it is not as specific to severe dehydration as sunken fontanels. Educationally, understanding the signs and symptoms of dehydration, especially in pediatric patients, is vital for nurses and healthcare providers. Knowing the specific indicators of severe dehydration, such as sunken fontanels in infants, helps in early recognition and prompt treatment to prevent complications. Nurses must be able to differentiate between mild, moderate, and severe dehydration to provide appropriate and timely interventions for pediatric patients.

Correct Answer: C

Rationale: In the management of pediatric asthma, the correct medication to administer during an asthma attack is a short-acting beta agonist, which is option C. Short-acting beta agonists like albuterol are considered rescue medications as they work quickly to open up the airways during an asthma exacerbation, providing immediate relief from symptoms such as wheezing, coughing, and shortness of breath. Option A, inhaled corticosteroids, are considered maintenance medications used to control asthma symptoms over the long term by reducing airway inflammation. They are not meant for quick relief during an acute asthma attack. Option B, leukotriene modifiers, are also maintenance medications that help reduce inflammation in the airways but are not as fast-acting as short-acting beta agonists in providing relief during an acute attack. Option D, long-acting beta agonists, are also maintenance medications that are used in combination with inhaled corticosteroids for long-term asthma control. They are not appropriate for use during an acute asthma attack due to their slower onset of action. In an educational context, it is crucial for nurses and parents to understand the differences between these medications to ensure appropriate management of pediatric asthma. Proper education on the use of rescue medications like short-acting beta agonists during acute exacerbations can help prevent complications and improve outcomes for children with asthma.

Correct Answer: A

Rationale: In the context of caring for a child with a recent concussion, the priority assessment is to assess for signs of increased intracranial pressure (ICP), making option A the correct answer. This is crucial because a concussion can lead to swelling or bleeding inside the brain, potentially causing increased ICP, which can be life-threatening if not promptly addressed. Option B, monitoring for difficulty swallowing, while important, is not the priority in this scenario as it is not directly related to the potential complications of a concussion such as increased ICP. Option C, assessing for skin integrity around the injury site, is also important but not as critical as monitoring for signs of increased ICP. Option D, evaluating the child's ability to perform tasks, is not the priority when assessing a child with a recent concussion as it does not directly address the immediate risks associated with increased ICP. Educationally, understanding the priority assessments in caring for a child with a concussion is essential knowledge for nurses working in pediatric settings. Recognizing the signs and symptoms of increased ICP and understanding the urgency of addressing them promptly can help prevent serious consequences and improve patient outcomes.

Correct Answer: A

Rationale: In caring for a child with suspected rotavirus, the priority intervention is administering an oral rehydration solution (Option A). Rotavirus commonly causes severe diarrhea and vomiting, leading to dehydration. Oral rehydration solutions are crucial in replenishing lost fluids and electrolytes, preventing complications like electrolyte imbalances and hypovolemic shock. Providing intravenous fluids (Option B) may be necessary if the child is severely dehydrated or unable to tolerate oral fluids. However, oral rehydration is preferred as the initial intervention if the child can tolerate it. Administering antiemetic medications (Option C) may help control vomiting, but managing dehydration through fluid replacement is the priority in this scenario. Providing a high-fiber diet (Option D) is not appropriate during acute illness with diarrhea and vomiting, as fiber can exacerbate gastrointestinal symptoms and worsen dehydration. Educationally, understanding the importance of fluid and electrolyte balance in pediatric patients with viral gastroenteritis like rotavirus is essential for nurses. Recognizing the priority interventions based on the child's clinical presentation is crucial for providing safe and effective care.

Correct Answer: A

Rationale: In caring for a child receiving total parenteral nutrition (TPN), it is crucial for the nurse to prioritize monitoring the child's blood glucose levels. This is because TPN is a high concentration of glucose and can lead to hyperglycemia if not properly monitored. Hyperglycemia can result in serious complications such as electrolyte imbalances, dehydration, and potential harm to vital organs. By closely monitoring blood glucose levels, the nurse can intervene promptly if any abnormalities are detected, thus ensuring the child's safety and well-being. Monitoring the child's blood pressure (option B) is important in general patient care; however, in the context of a child receiving TPN, monitoring blood glucose levels takes precedence due to the potential risks associated with hyperglycemia. Providing supplemental vitamin K (option C) is essential for patients on long-term TPN to prevent deficiencies; however, it is not the priority in this situation where immediate monitoring of blood glucose is crucial. Encouraging oral intake as soon as possible (option D) is not appropriate for a child receiving TPN as the primary source of nutrition is intravenous. Introducing oral intake prematurely can lead to complications and is not recommended until the healthcare team determines it is safe to do so. In an educational context, understanding the priority interventions in caring for a child on TPN is vital for nurses working in pediatric settings. This knowledge ensures safe and effective care delivery, promoting positive patient outcomes and minimizing potential complications.