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. What is a common sign of congenital hip dysplasia in infants?

Correct answer: B

Rationale: Limited range of motion in the hip, often noted as a limitation in abduction, is a common sign of congenital hip dysplasia. This limitation is due to the abnormal development of the hip joint, affecting its movement. Symmetrical hip movement (Choice A) is not a characteristic sign of congenital hip dysplasia. Swelling of the knees (Choice C) is not typically associated with this condition. Dislocated patella (Choice D) refers to a different anatomical structure and is not a common sign of congenital hip dysplasia.

3. What is the priority assessment for a child with suspected appendicitis?

Correct answer: D

Rationale: The priority assessment for a child with suspected appendicitis is 'Pain level.' Evaluating the pain level, particularly in the lower right quadrant, is crucial as it helps in determining the severity of the condition, leading to prompt diagnosis and treatment. Monitoring temperature, heart rate, and respiratory rate are important aspects of assessment; however, they are secondary to assessing the pain level in cases of suspected appendicitis. Pain assessment is key in diagnosing this condition since the classic presentation includes abdominal pain that often starts around the umbilicus and then localizes to the right lower quadrant.

4. What is a causative factor of Hirschsprung disease?

Correct answer: C

Rationale: The correct answer is C: Absence of parasympathetic ganglion cells in a portion of the colon. Hirschsprung disease is a congenital condition characterized by the absence of nerve cells (ganglia) in parts of the colon. This absence leads to a lack of peristalsis in the affected segment, resulting in severe constipation and bowel obstruction. Choices A, B, and D are incorrect. Choice A describes symptoms of diarrhea rather than a causative factor of Hirschsprung disease. Excessive peristaltic movement (choice B) is not a causative factor but rather the opposite, as Hirschsprung disease is associated with reduced peristalsis. Choice D, which refers to intussusception, is a different condition unrelated to Hirschsprung disease.

5. What is a common symptom of a urinary tract infection in children?

Correct answer: A

Rationale: Fever is a common symptom of a urinary tract infection in children. It is often accompanied by other symptoms such as pain or discomfort. Weight loss (choice B) is not a typical symptom of a urinary tract infection in children. Abdominal pain (choice C) can be present but is not as specific as fever. Increased appetite (choice D) is not a common symptom of a urinary tract infection.

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