The nurse receives shift report on a pediatric medical-surgical ...

[FButt]

The nurse receives shift report on a pediatric medical-surgical unit. The nurse has been assigned four clients for the shift. Which client does the nurse plan to assessment first based on the increased risk for dehydration?
 
  A) A 4-year-old child with a broken leg
  B) A 15-month-old child with tachypnea
  C) A 16-year-old child with migraine headaches
  D) A 10-year-old child with cellulitis of the left leg

Question 2

An older adult client is brought to the emergency department from a long-term care facility.
 
  The client has been experiencing fever, nausea, and vomiting for the past 2 days. The client denies thirst. Urine dipstick indicates a decreased urine specific gravity. Based on this data, which diagnosis does the nurse anticipate?
  A) Congestive heart failure
  B) Dehydration
  C) Fluid overload
  D) Normal changes of aging

[johnharpe]

Answer to Question 1

Answer: B

The pediatric client with the greatest risk for dehydration is the client who is under 2 years of age experiencing tachypnea which increases insensible fluid loss. The pediatric client with a chronic or acute condition that does not directly affect the GI or electrolyte system (migraine headache, broken leg, or cellulitis) is at a lower risk than is a toddler with a condition that increases insensible water loss.

Answer to Question 2

Answer: B

Older adult clients are less able to concentrate their urine, making them susceptible to dehydration. In addition, there is a deficit of the thirst response. However, fever, nausea, and vomiting resulting from these changes are not considered normal. The client's symptoms of nausea and vomiting suggest decreased intake and increased output through vomiting, placing the client at risk for dehydration. Congestive heart failure and fluid overload would present with respiratory difficulty and peripheral edema.

[FButt]

Excellent

[bitingbit]

Thanks for the timely response, appreciate it