which finding suggests fluid volume deficit in an infant presenting with vomiting and diarrhea for 2 days
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Nursing Elites

ATI RN

RN Nursing Care of Children 2019 With NGN

1. Which finding suggests fluid volume deficit in an infant presenting with vomiting and diarrhea for 2 days?

Correct answer: B

Rationale: A sunken fontanel is a classic sign of dehydration in infants, indicating a fluid volume deficit. In dehydration, the fontanel sinks due to decreased fluid volume in the body. Increased blood pressure (Choice A) is not typically associated with dehydration in infants. Decreased pulse rate (Choice C) is not a common finding in fluid volume deficit, as the body tries to increase the heart rate to compensate for decreased volume. Low urine specific gravity (Choice D) may be seen in dehydration, but it is not as specific or as easily observable as a sunken fontanel.

2. The child is admitted to the hospital unit newly diagnosed with retinoblastoma. Which clinical manifestation does the nurse anticipate upon assessment?

Correct answer: A

Rationale: The correct answer is A: A white reflex. The 'white reflex' or leukocoria is a common sign of retinoblastoma. It occurs when the light reflects off the tumor in the eye, giving the pupil a white appearance instead of the normal red reflex. Blue-tinged sclerae (choice B) and yellow-tinged sclerae (choice D) are not typical manifestations of retinoblastoma. A red reflex (choice C) is the normal reflection seen in the eye when light is shone on it and is not associated with retinoblastoma.

3. The clinic nurse is instructing parents about caring for a toddler with ascariasis (common roundworm). Which statement made by the parents indicates a need for further teaching?

Correct answer: B

Rationale: Roundworm (ascariasis) is typically transmitted through ingestion of contaminated soil, not directly from person to person. This statement indicates a misunderstanding requiring clarification.

4. A child has a planned hospitalization in a few weeks, and the client and family appear very stressed. Which nursing action will minimize their stress?

Correct answer: D

Rationale: The correct nursing action to minimize the stress of the child and family is giving a tour of the hospital unit or surgical area. Familiarizing them with the hospital environment can help reduce their anxiety by allowing them to see where the child will be staying and the surroundings. Choices A, B, and C do not directly address the need to reduce stress by providing a tangible way to alleviate anxiety through exposure to the hospital setting.

5. In addition to injuries, what are the leading causes of death in adolescents ages 15 to 19 years?

Correct answer: B

Rationale: Suicide and homicide are significant causes of death in adolescents, highlighting the need for mental health and violence prevention programs.

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