how should a nurse assess hydration status in a child with vomiting and diarrhea how should a nurse assess hydration status in a child with vomiting and diarrhea
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Nursing Elites

HESI LPN

Nutrition Final Exam

1. How should hydration status be assessed in a child with vomiting and diarrhea?

Correct answer: A

Rationale: Checking skin turgor and mucous membranes is the appropriate method to assess hydration status in a child with vomiting and diarrhea. Skin turgor is an indicator of skin elasticity, which decreases when an individual is dehydrated. Mucous membranes, such as the inside of the mouth, can also show signs of dehydration like dryness. Measuring blood glucose levels (choice B) is not relevant to assessing hydration status in this scenario. Assessing heart rate and blood pressure (choice C) is important in evaluating the overall condition of a child but may not directly indicate hydration status. Evaluating bowel sounds (choice D) is more related to assessing gastrointestinal function rather than hydration status.

2. A nurse in a provider's office is obtaining the health and medication history of a client who has a respiratory infection. The client tells the nurse that she is not aware of any allergies, but that she did develop a rash the last time she was taking an antibiotic. Which of the following information should the nurse give to the client?

Correct answer: A

Rationale: The nurse should advise the client to document the exact medication taken to identify potential allergies and prevent adverse reactions. This is important as the client developed a rash previously while taking an antibiotic, indicating a possible allergic reaction. Choice B is not appropriate as switching antibiotics without proper evaluation can be risky. Choice C is incorrect as rashes should not be dismissed without further investigation, especially in the context of taking medication. Choice D is also not recommended as re-taking the same antibiotic without clarifying the allergic reaction can lead to a potentially severe outcome.

3. What explanation should the nurse give a parent about the purpose of a tetanus toxoid injection for their child?

Correct answer: B

Rationale: The correct answer is B: Long-lasting active immunity is conferred. Tetanus toxoid injection works by stimulating the child's body to produce its antibodies, providing long-lasting active immunity. Choice A is incorrect because passive immunity is not conferred for life; it is temporary and involves receiving antibodies rather than producing them internally. Choice C is incorrect as the immunity conferred by the tetanus toxoid injection is not lifelong natural immunity but rather active immunity stimulated by the body's immune response. Choice D is also incorrect since passive natural immunity is not conferred by the tetanus toxoid injection, and it is not temporary.

4. In the context of an average ejaculation, which of the following statements is true about sperm?

Correct answer: C

Rationale: Out of millions of sperm released during ejaculation, only a small fraction, about 1 in 1,000, will approach the ovum. This statement is true as sperm face many obstacles and challenges on their journey to reach and fertilize an ovum. Choice A is incorrect because the average count of sperm in an ejaculate is typically in the millions, not billions. Choice B is incorrect as sperm do not find the ovum by following the current of fluid; they navigate using other mechanisms. Choice D is incorrect because while some sperm may move randomly in the vagina, the ones that approach the ovum do so through a more purposeful and directed movement.

5. A health program that aims to reduce the incidence of chronic diseases through lifestyle modifications is an example of:

Correct answer: A

Rationale: The correct answer is A: Primary prevention. Primary prevention focuses on preventing the development of diseases or injuries before they occur by promoting healthy behaviors and lifestyles. In this scenario, the health program targeting lifestyle modifications to reduce chronic diseases aligns with primary prevention efforts. Choice B, secondary prevention, involves early detection and treatment to prevent the progression of disease. Choice C, tertiary prevention, focuses on managing and treating existing diseases to prevent complications. Choice D, quaternary prevention, relates to actions taken to mitigate or avoid the consequences of unnecessary or excessive interventions in healthcare.

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