The Client with Diarrhea, Gastroenteritis, or Dehydration
2. Insert an I.V. and infuse fl uids as ordered
bulk in the stool. Fat is necessary for brain growth in the fi rst year of life. A high-residue diet would result in bulkier stools and increased gas production, which will collect in the colostomy bag. Therefore, a high-residue diet is not indicated.
CN: Basic care and comfort; CL: Apply
53.
2. Toilet-training is commonly more diffi cult for children who have undergone surgery for Hirschsprung’s disease than it is for other children.This is because of the trauma to the area and the associated psychological implications. Abdominal distention is an early sign of infection and therefore the parents need to report it to the physician. Typi- cally, dietary restrictions are not required. Usually the infant is placed on an age-appropriate diet. Vita- min supplementation is not necessary if the infant’s dietary intake is adequate.
CN: Physiological adaptation;
CL: Evaluate
The Client with Diarrhea,
59.
8.2 mL/hour2.2 lb/kg = 9 lb/X kg X = 9 ÷ 2.2
X = 4.09 kg, rounded to 4.1 kg 4.1 kg × 2 mL/kg = 8.2 mL/hour
CN: Pharmacological and parenteral therapies; CL: Apply
60.
3. The intravenous infusion is secured appro- priately; the sandbag is used to limit movement of the leg. It is not necessary to also secure the unin- volved extremity. The intravenous site should be visible; the nurse should not cover it with tape. The nurse should use an infusion pump with monitoring alarms, and check the infusion rate every hour.CN: Safety and infection control;
CL: Evaluate
61.
1. Typically, an infant hospitalized with severe diarrhea receives fl uid replacement intrave- nously rather than orally. Oral fl uids and food are usually withheld. Although activities such as plac- ing a mobile over the crib, speaking to the infant, or turning on the television may provide distraction for or help in calming the infant, a fussy infant receiv- ing nothing by mouth is usually best comforted by providing a pacifi er to satisfy sucking needs.CN: Health promotion and maintenance;
CL: Synthesize
62.
2. Given this infant’s history of gastroenteri- tis, the priority nursing diagnosis would be Defi cient fl uid volume. With gastroenteritis, vomiting and diarrhea occur, leading to the loss of fl uids. This loss of fl uids is problematic in infants because a higher proportion of their body weight is water. Pain is not a priority nursing diagnosis, although the nurse should continue to assess the infant for pain. There are no data to indicate impaired parenting. Impaired urinary elimination is related to the infant’s fl uid volume defi cit resulting from vomiting and diarrhea associated with gastroenteritis. If the infant’s fl uid volume defi cit is not corrected, then this nursing diagnosis may become the priority.CN: Physiological adaptation; CL: Analyze
63.
1. The outcome of moist mucous membranes indicates adequate hydration and fl uid balance, showing that the problem of fl uid volume defi cit has been corrected. Although a normal bowel move- ment, ability to tolerate intravenous fl uids, and an increasing time interval between bowel move- ments are all positive signs, they do not specifi cally address the problem of defi cient fl uid volume.CN: Physiological adaptation; CL: Analyze with the organism, which is found in the stool.
A stool specimen will show increased numbers of WBCs, blood, and mucus. Vomiting and loose stools can result in severe dehydration and electrolyte imbalance. Thus, the nurse should record intake, output, and daily weights. There is no need for strict isolation; masks are not needed as shigella is not transmitted by airborne methods.
CN: Physiological adaptation;
CL: Synthesize
56.
3. The absence of tears is typically found when moderate dehydration is observed as the body attempts to conserve fl uids. Other typical fi ndings associated with moderate dehydration include a dry mouth, sunken eyes, poor skin turgor, and an increased pulse rate. Deep, rapid respirations are associated with severe dehydration. Decreased perspiration, not diaphoresis, would be seen with moderate dehydration. The specifi c gravity of urine increases with decreased output in the presence of dehydration.CN: Reduction of risk potential;
CL: Analyze
57.
4. An infant with severe diarrhea will experi- ence some degree of dehydration. In an 8-month-old child, the anterior fontanel has not closed. There- fore, a depressed anterior fontanel would be an important fi nding. Additionally, the infant would exhibit dry mucous membranes, lethargy, hyperac- tive bowel sounds, dark urine, and sunken eyeballs.Skin turgor would be decreased or delayed (e.g., slow to return when pinched).
CN: Reduction of risk potential;
CL: Analyze
58.
2. Because an infant experiencing severe diarrhea is at high risk for Defi cient fl uid volume, the nurse needs to evaluate the infant’s fl uid bal- ance status by weighing the infant at least every day. Body weight is the best indicator of hydration status because a higher proportion of an infant’s body weight is water, compared with an adult. Ini- tially, the infant with severe diarrhea is not allowed liquids but is given fl uids intravenously. Therefore, monitoring the oral intake of formula is inappro- priate. Although checking the anterior fontanel for depression or bulging provides information about hydration status, this method is not considered the best indicator of the infant’s fl uid balance. Monitor- ing skin turgor can provide information about fl uid volume status. The abdomen is commonly used to assess skin turgor in an infant because it is a large surface area and can be accessed quickly. However, weight is the best indicator of fl uid balance.CN: Physiological adaptation;
CL: Synthesize
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the child with severe gastroenteritis is placed in a private room until the causative organism is deter- mined, to prevent transmission and protect others, including clients, families, and staff, from acquiring the infection. Because gastroenteritis is usually viral in origin and highly contagious, disposable eating utensils should be used to prevent transmission. For the child with gastroenteritis, double-bagging all lin- ens is appropriate to prevent possible transmission from contaminated linens.
CN: Safety and infection control;
CL: Synthesize
68.
1, 2, 3, 5. Accurate intake and output recording includes noting all intake, including I.V. fl uids; noting output, such as emesis and stool; weighing diapers;measuring weight daily; measuring urine specifi c gravity; monitoring serum electrolytes; and monitor- ing for signs of dehydration. Children who are dehy- drated must receive suffi cient fl uid intake. Restricting fl uids just prior to weighing the child will not alter the accuracy of the weight, and the nurse should con- tinue to encourage fl uids for this dehydrated child.
CN: Management of care; CL: Analyze
69.
1. Potassium chloride is readily excreted in the urine. Before adding potassium chloride to the intravenous fl uid, the nurse should ascer- tain whether the child can void; if not, potassium chloride may build up in the serum and cause hyperkalemia. An electrocardiogram could be done during intravenous potassium replacement therapy to evaluate for these changes. Having a stool daily is important but, because potassium is primarily excreted in the urine, the child’s ability to void must be verifi ed. Serum calcium levels do not indicate the child’s ability to tolerate potassium replacement.CN: Pharmacological and parenteral therapies; CL: Analyze
70.
3. An early sign of circulatory overload is moist rales or crackles heard when auscultating over the chest wall. Elevated blood pressure, engorged neck veins, a wide variation between fl uid intake and output (with a higher intake than output), short- ness of breath, increased respiratory rate, dyspnea, and cyanosis occur later.CN: Reduction of risk potential;
CL: Analyze
71.
1. After having Salmonella enteritidis, some clients become chronic carriers of the causative organism and remain infectious for a long time as the organism continues to be shed from the body.During this time, the child is still considered infec- tious. No antitoxin is available to treat or prevent Salmonella infections.
CN: Physiological adaptation;
CL: Evaluate
64.
1. Children hospitalized with gastroenteritis are usually not allowed fl uids by mouth to allow the gastrointestinal tract time to rest. Antibiotics are not indicated unless there is a bacterial infection. A mist tent would be used to treat respiratory disorders, not gastroenteritis. Once the infant is allowed oral intake, clear fl uids are used initially.CN: Health promotion and maintenance;
CL: Create
65.
1. The usual way to treat an infant hospi- talized with gastroenteritis is to keep the infant nothing-by-mouth status to rest the gastrointestinal tract. The resulting fl uid volume defi cit is treated with intravenous fl uids. When the infant’s condi- tion is controlled (e.g., when vomiting subsides), clear liquids are then started slowly. Formula and juice will be started once the infant’s vomiting has subsided and the infant has demonstrated the ability to tolerate clear liquids for a period of time. In this situation, there is no need to test the infant’s blood every day for anemia. Most likely, the infant’s serum electrolyte levels would be monitored closely. Typi- cally, an infant is placed in a private room because gastroenteritis is most commonly caused by a virus that is easily transmitted to others.CN: Physiological adaptation;
CL: Evaluate
66.
2. The nurse’s best course of action would be to support the mother. This is best done by convey- ing understanding and encouraging the mother to visit or call. Telling the mother that she shouldn’t leave and that the child is very sick is critical and insensitive. Additionally, it implies guilt should the mother leave. Commenting that the child does not need anyone is not appropriate or true. Toddlers, in particular, need family members present because of the stresses associated with hospitalization. They experience separation anxiety, a normal aspect of development, and need constancy in their environ- ment. Asking the mother to fi nd someone else to stay with her children is inappropriate. The chil- dren at home also need the support of the mother and/or other family members to minimize the dis- ruptions in family life resulting from the toddler’s hospitalization and to maintain consistency.CN: Psychosocial adaptation;
CL: Synthesize
67.
1. For the child with severe gastroenteritis, diarrhea is a problem; it exposes all persons caring for the child to possibly infectious body fl uids. Sub- sequently, any other clients being cared for by these individuals are also at risk. Therefore, the nurse should institute standard precautions, including good handwashing and use of appropriate personal protective equipment (gowns, gloves, eye protec- tion) to minimize the risk for exposure. Typically,Billings_Part 2_Chap 2_Test 4.indd 246
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because doing so rewards the behavior and prevents the child from developing self-control. Toddlers do not possess the capacity to understand explanations about behavior. Expressing disappointment in the child’s behavior or telling her that she is being a bad girl reinforces feelings of guilt and shame, thus interfering the child’s ability to develop a sense of autonomy.
CN: Health promotion and maintenance;
CL: Evaluate
77.
1. Hospitalization is a traumatic time for a child, and it takes some time to readjust to the home environment. The child may regress at home for a period until she feels comfortable. Children normally do not dislike their home environment; in fact, they usually are eager to get home to familiar surroundings where they feel safe.CN: Health promotion and maintenance;
CL: Synthesize
The Client with Appendicitis
78.
1, 3, 4. Cold is a vasoconstrictor and sup- plies some degree of anesthesia. The child is usually more comfortable on his side with his legs fl exed to take the strain off the infl amed appendix. Limiting the child’s activity puts less stress on the infl amed appendix and lessens the discomfort. Heat increases circulation to an area, causing more engorgement and pain and, possibly, rupture of the appendix.Heat is contraindicated in any situation where rupture or perforation is a possibility. A cathartic is contraindicated when appendicitis is suspected.
Increasing peristalsis can cause the appendix to rupture.
CN: Physiological adaptation;
CL: Synthesize
79.
4. The nurse should use the FACES Pain Rating Scale for children or cognitively impaired clients so that the client can use a picture to identify the pain. The visual analog and numerical scales are used with adults. The Short Form McGill Question- naire allows the client to give simple descriptions of pain by sensation and perception, which is inappro- priate for a child.CN: Basic care and comfort;
CL: Analyze
80.
1. The nurse should administer the Tylenol with Codeine as the client indicates he is having pain. Although the child reports less severe pain, he is still experiencing pain. The nurse will also want the child to have less pain because he will need to be more active during the day. Assessing the child later will likely cause the pain to have increased72.
2. After clear liquids, the foods of choice are soft foods. These foods should be easily digested and low in fat. Additionally, the foods should be non-bulk-forming. Bananas and rice cereal are low in fat and easy to digest. Muffi ns and eggs, as well as sausage and pancakes, are typically high in fat and would be avoided. Although a bagel is low in fat, bran cereal is high in fi ber and would be avoided because it may cause more diarrhea.CN: Basic care and comfort; CL: Synthesize
73.
1. Dietary management following rehydra- tion for diarrhea and mild dehydration would include offering the child a regular diet. Following rehydration, there is no need for the child to be on a special diet, such as a clear liquid, full liquid, or soft diet.CN: Basic care and comfort; CL: Evaluate
74.
3. Diarrhea related to Salmonella bacilli is commonly spread by raw or undercooked fowl and eggs, pet turtles, and kittens. Food poisoning caused by Staphylococcus species is commonly spread by inadequately cooked or refrigerated custards, cream fi llings, or mayonnaise. Psittacosis, a respiratory illness, may be spread by canaries. Contaminated, unwashed fruit is associated with typhoid fever (caused by Salmonella typhi), a disorder rarely seen in the United States.CN: Physiological adaptation;
CL: Analyze
75.
3. The “no” behavior demonstrated by a toddler is typical of this age group as the child attempts to be self-assertive as an individual. The negativism does not demonstrate an inherited personality trait or disinterest. Rather, it refl ects the developmental task of establishing autonomy. The toddler is attempting to exert control over the envi- ronment. It is too early to assess leadership qualities in a toddler.CN: Health promotion and maintenance;
CL: Analyze
76.
1. The child is demonstrating behavior asso- ciated with temper tantrums, which are relatively frequent normal occurrences during toddlerhood as the child attempts to develop a sense of autonomy.The development of autonomy requires opportuni- ties for the child to make decisions and express individuality. Ignoring the outbursts is probably the best strategy. Doing so avoids rewarding the behav- ior and helps the child to learn limits, promoting the development of self-control. However, the mother should intervene in a temper tantrum if the child is likely to injure herself. Allowing the child to have what she wants occasionally would typically add to the problems associated with temper tantrums,
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84.
1. Sudden relief of pain in a client with appendicitis may indicate that the appendix has ruptured. Rupture relieves the pressure within the appendix but spreads the infection to the peritoneal cavity. Periumbilical pain (pain centered around the navel), vomiting, and abdominal tenderness on palpation are common fi ndings associated with appendicitis.CN: Physiological adaptation;
CL: Analyze
85.
1. The priority assessment after an appen- dectomy would be the dressing over the surgical site to determine whether there is any drainage or bleeding. The surgical dressing should be clean, dry, and intact. Once the dressing has been assessed, the nurse would assess the intravenous infusion site, assess the NG tube to be sure it is functioning, and fi nally, determine the degree of pain the client is experiencing.CN: Physiological adaptation;
CL: Analyze
86.
2. After an appendectomy, the client who develops peritonitis typically has an NG tube in place. When a client complains of nausea, the nurse would fi rst check to ensure that the NG tube is functioning correctly, because the client’s nau- sea may be related to a blockage of the NG tube. If the tube is clogged, it can be irrigated with nor- mal saline. An antiemetic may be given, but only after the nurse has determined that the NG tube is functioning properly. Postoperative orders usually include an antiemetic. Typically, the nurse would notify the surgeon if the client did not obtain relief from irrigation of the NG tube or administration of an ordered antiemetic. Although taking the client’s blood pressure is an important postoperative nurs- ing activity, it is unrelated to relieving the client’s nausea.CN: Physiological adaptation;
CL: Synthesize
87.
1. After an appendectomy for a ruptured appendix, assuming the semi-Fowler’s or a right side-lying position helps localize the infection.These positions promote drainage from the perito- neal cavity and decrease the incidence of subdia- phragmatic abscess.
CN: Physiological adaptation;
CL: Synthesize
88.
2. Adolescents are concerned about the immediate state and functioning of their bodies.The adolescent needs to know whether any changes (e.g., illness, trauma, surgery) will alter her lifestyle or interfere with her quest for physical perfection.
and be more diffi cult to manage. While distraction is appropriate for short-term pain, such as from a needlestick or pain that the child might be able to manage himself, postoperative pain should be relieved with medication.
CN: Basic care and comfort;
CL: Synthesize
81.
1. The most helpful question would be to determine the location of the pain when it started.The pain associated with appendicitis usually begins in the periumbilical area, then progresses to the right lower quadrant. After the nurse has deter- mined the location of the pain, asking about what was done for the pain would be appropriate. Asking about the child’s usual bowel movement pattern is a general question unrelated to child’s condition.
Children with appendicitis may have diarrhea or constipation. Additionally, knowledge about the child’s usual pattern would not be a priority because the child with appendicitis typically is not hospital- ized long enough to reestablish the normal pattern.
Although the characteristics of the pain are impor- tant, asking if the pain is continuous or intermit- tent is vague and general because the pain could be associated with numerous conditions. With appen- dicitis, the client’s pain may begin as intermittent, but it eventually becomes continuous.
CN: Physiological adaptation;
CL: Analyze
82.
3. Application of an ice bag may help to relieve pain by decreasing circulation to the area.A heating pad is contraindicated because heat may increase circulation to the appendix, possibly lead- ing to rupture. Rectal tubes are contraindicated because they stimulate bowel motility and can exac- erbate abdominal pain. Also, they would be ineffec- tive because accumulation of gas in the lower bowel is not likely to be the cause of the child’s discomfort.
Because narcotics can mask the child’s symptoms, such as pain and discomfort, and they also decrease bowel motility, they are not given until after a defi nitive diagnosis has been made.
CN: Physiological adaptation; CL: Create
83.
2. Manifestations of appendicitis include decreased or absent bowel sounds. Normally, bowel sounds are heard every 10 to 30 seconds. Therefore, bowel sounds heard twice in 2 minutes suggests appendicitis. Normally, the contour of the male adolescent abdomen is fl at to slightly rounded, and tympany is typically heard when auscultating over most of the abdomen. A cremasteric refl ex is normal for male adolescents.CN: Physiological adaptation;
CL: Analyze
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