The Child with a Fluid and Electrolyte Alteration

MULTIPLE CHOICE

1. The parents of a child with acid-base imbalance ask the nurse about mechanisms that regulate acid-base balance. Which statement by the nurse accurately explains the mechanisms regulating acid-base balance in children?

a.
The respiratory, renal, and chemical-buffering systems regulate acid-base in the body.
b.
The kidneys balance acid; the lungs balance base.
c.
The cardiovascular and integumentary systems work together to control acid-base.
d.
The skin, kidney, and endocrine systems control the body’s acid-base.

ANS: A

The acid-base system is regulated by chemical buffering, respiratory control of carbon dioxide, and renal regulation of bicarbonate and secretion of hydrogen ions. Both the kidneys and the lungs, along with the buffering system, contribute to acid-base balance. Neither system regulates acid or base balances exclusively. The cardiovascular and integumentary systems are not part of acid-base regulation in the body. Chemical buffers, the lungs, and the kidneys work together to keep the blood pH within a normal range.

DIF: Cognitive Level: Application REF: p. 338

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

2. A child has a 2-day history of vomiting and diarrhea. He has hypoactive bowel sounds and an irregular pulse. Electrolyte values are sodium, 139 mEq/L; potassium, 3.3 mEq/L; and calcium, 9.5 mg/dL. This child is likely to have which of the following electrolyte imbalances?

a.
Hyponatremia
b.
Hypocalcemia
c.
Hyperkalemia
d.
Hypokalemia

ANS: D

A serum potassium level less than 3.5 mEq/L is considered hypokalemia. Clinical manifestations of hypokalemia include muscle weakness, decreased bowel sounds, cardiac irregularities, hypotension, and fatigue. The normal serum sodium level is 135 to 145 mEq/L. A level of 139 mEq/L is within normal limits. A serum calcium level less than 8.5 mg/dL is considered hypocalcemia. A serum potassium level greater than 5 mEq/L is considered hyperkalemia.

DIF: Cognitive Level: Analysis REF: p. 339

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

3. Which statement best describes why infants are at greater risk for dehydration than older children?

a.
Infants have an increased ability to concentrate urine.
b.
Infants have a greater volume of intracellular fluid.
c.
Infants have a smaller body surface area.
d.
Infants have an increased extracellular fluid volume.

ANS: D

The larger ratio of extracellular fluid to intracellular fluid predisposes the infant to dehydration. Because the kidneys are immature in early infancy, there is a decreased ability to concentrate the urine. Infants have a larger proportion of fluid in the extracellular space. Infants have a proportionately greater body surface area in relation to body mass, which creates the potential for greater fluid loss through the skin and gastrointestinal tract.

DIF: Cognitive Level: Comprehension REF: p. 337

OBJ: Nursing Process Step: Assessment MSC: Health Promotion and Maintenance

4. Which assessments are most relevant to the care of an infant with dehydration?

a.
Temperature, heart rate, and blood pressure
b.
Respiratory rate, oxygen saturation, and lung sounds
c.
Heart rate, capillary refill, and skin color
d.
Diet tolerance, bowel function, and abdominal girth

ANS: C

Changes in heart rate, capillary refill, and skin color are early indicators of impending shock in the child. Children can compensate and maintain an adequate cardiac output when they are hypovolemic. Blood pressure is not as reliable an indicator of shock as are changes in heart rate, sensorium, and skin color. Respiratory assessments will not provide data about impending hypovolemic shock. Diet tolerance, bowel function, and abdominal girth are not as important indicators of shock as heart rate, capillary refill, and skin color.

DIF: Cognitive Level: Analysis REF: p. 343|p. 346

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

5. Which factor is the most important in determining the rate of fluid replacement in the dehydrated child?

a.
The child’s weight
b.
The type of dehydration
c.
Urine output
d.
Serum potassium level

ANS: B

Isotonic and hypotonic dehydration resuscitation involves fluid replacement over 24 hours. Hypertonic dehydration involves a slower replacement rate to prevent a sudden decrease in the sodium level. The child’s weight determines the amount of fluid needed, not the rate of fluid replacement. One milliliter of body fluid is equal to 1 gram of body weight; therefore a loss of 1 kilogram (2.2 pounds) is equal to 1 liter of fluid. Urine output is not a consideration for determining the rate of administration of replacement fluids. Potassium level is not as significant in determining the rate of fluid replacement as the type of dehydration.

DIF: Cognitive Level: Analysis REF: p. 344

OBJ: Nursing Process Step: Planning MSC: Physiological Integrity

6. Which is the priority nursing intervention for a 6-month-old infant hospitalized with diarrhea and dehydration?

a.
Estimating insensible fluid loss
b.
Collecting urine for culture and sensitivity
c.
Palpating the posterior fontanel
d.
Measuring the infant’s weight

ANS: D

Weight is a crucial indicator of fluid status. It is an important criterion for assessing hydration status and response to fluid replacement. Infants have a greater total body surface area and therefore a greater potential for fluid loss through the skin. It is not possible to measure insensible fluid loss. Urine for culture and sensitivity is not usually part of the treatment plan for the infant who is dehydrated from diarrhea. The posterior fontanel closes by 2 months of age. The anterior fontanel can be palpated during an assessment of an infant with dehydration.

DIF: Cognitive Level: Application REF: p. 346

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

7. What assessment should the nurse make before initiating an intravenous (IV) infusion of dextrose 5% in 0.9% normal saline solution with 10 mEq of potassium chloride for a child hospitalized with dehydration?

a.
Fluid intake
b.
Number of stools
c.
Urine output
d.
Capillary refill

ANS: C

Potassium chloride should never be added to an IV solution in the presence of oliguria or anuria (urine output less than 0.5 mL/kg/hr). Fluid intake does not provide information about renal function. Stool count sheds light on intestinal function. Renal function is the concern before potassium chloride is added to an IV solution. Assessment of capillary refill does not provide data about renal function.

DIF: Cognitive Level: Analysis REF: p. 344

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

8. A nurse is teaching parents about diarrhea. Which statement by the parents indicates understanding of the teaching?

a.
Diarrhea results from a fluid deficit in the small intestine.
b.
Organisms destroy intestinal mucosal cells, resulting in an increased intestinal surface area.
c.
Malabsorption results in metabolic alkalosis.
d.
Increased motility results in impaired absorption of fluid and nutrients.

ANS: D

Increased motility and rapid emptying of the intestines result in impaired absorption of nutrients and water. Electrolytes are drawn from the extracellular space into stool, and dehydration results. Diarrhea results from fluid excess in the small intestine. Destroyed intestinal mucosal cells result in decreased intestinal surface area. Loss of electrolytes in the stool from diarrhea results in metabolic acidosis.

DIF: Cognitive Level: Application REF: p. 347

OBJ: Nursing Process Step: Evaluation MSC: Physiological Integrity

9. Which is the best nursing response to a parent asking about antidiarrheal medication for her 18-month-old child?

a.
“It is okay to give antidiarrheal medication to a young child as long as you follow the directions on the box for correct dosage.”
b.
“Antidiarrheal medication is not recommended for young children because it slows the body’s attempt to rid itself of the pathogen.”
c.
“I’m sure your child won’t like the taste so give her extra fluids when you give the medication.”
d.
“Antidiarrheal medication will decrease the frequency of stools, but give your child Gatorade to maintain electrolyte balance.”

ANS: B

Antidiarrheal medications may actually prolong diarrhea because the body will retain the organism causing the diarrhea, further increasing fluid and electrolyte losses. The use of these medications is not recommended for children aged younger than 2 years because of their binding nature and potential for toxicity. It is not appropriate to advise a parent to use antidiarrheal medication for a child aged younger than 2 years. Education about appropriate oral replacement fluids includes avoidance of sugary drinks, apple juice, sports beverages, and colas.

DIF: Cognitive Level: Application REF: p. 349

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

10. Which is the primary intervention in treating a child with persistent vomiting?

a.
Detecting the cause of vomiting
b.
Preventing metabolic acidosis
c.
Positioning the child supine
d.
Recording intake and output

ANS: A

The primary focus of managing vomiting is detection of the cause and then treatment of the cause. Metabolic alkalosis results from persistent vomiting. Prevention of complications is the secondary focus of treatment. The child with persistent vomiting should be positioned upright or side-lying to prevent aspiration. Recording intake and output is a nursing intervention but it is not the primary focus of treatment.

DIF: Cognitive Level: Application REF: p. 351

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

11. Which is the best nursing response to give a parent about contacting the physician regarding an infant with diarrhea?

a.
“Call your pediatrician if the infant has not had a wet diaper for 6 hours.”
b.
“The pediatrician should be contacted if the infant has two loose stools in an 8-hour period.”
c.
“Call the doctor immediately if the infant has a temperature greater than 100° F.”
d.
“Notify the pediatrician if the infant naps more than 2 hours.”

ANS: A

No urine output in 6 hours needs to be reported because it indicates dehydration. Two loose stools in 8 hours is not a serious concern. If blood is obvious in the stool or the frequency increases to one bowel movement every hour for more than 8 hours, the physician should be notified. A fever greater than 101° F should be reported to the infant’s physician. It is normal for the infant who is not ill to nap for 2 hours. The infant who is ill may nap longer than the typical amount.

DIF: Cognitive Level: Application REF: p. 350

OBJ: Nursing Process Step: Planning MSC: Physiological Integrity

12. Which diet would the nurse recommend to the mother of a child who is having mild diarrhea?

a.
Rice, potatoes, bread, and cereal
b.
Bananas, rice, applesauce, and toast
c.
Apple juice, hamburger, and salad
d.
Whatever the child would like to eat

ANS: A

Bland but nutritional foods including complex carbohydrates (rice, potatoes, bread, and cereals) are recommended for mild diarrhea. Bananas, rice, applesauce, and toast used to be recommended for diarrhea (BRAT diet). These foods are easily tolerated but the BRAT diet is low in energy, density, fat, and protein. Fatty foods, spicy foods, and foods high in simple sugars should be avoided. The child should be offered foods he or she likes but should not be encouraged to eat fatty foods, spicy foods, and foods high in simple sugars.

DIF: Cognitive Level: Application REF: p. 348|p. 350

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

MULTIPLE RESPONSE

1. Which assessment findings indicate to the nurse that a child has fluid volume excess? Select all that apply.

a.
Weight gain
b.
Decreased blood pressure
c.
Moist breath sounds
d.
Poor skin turgor
e.
Rapid bounding pulse

ANS: A, C, E

A child with fluid volume excess will have weight gain, moist breath sounds due to the excess fluid in the pulmonary system, and a rapid bounding pulse. Other signs seen with fluid volume excess are increased blood pressure, edema, and fatigue. Decreased blood pressure and poor skin turgor are signs of fluid volume deficit.

DIF: Cognitive Level: Analysis REF: p. 345

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

SHORT ANSWER

1. A nurse is totaling an 8 hour output for a child admitted with vomiting and diarrhea. The child had an emesis at 0800 of 50 mL and an emesis at 1200 of 35 mL. The child had 3 diapers weighed and calculated during the 8 hour shift: 1 diaper (urine and stool) = 30 mL; 1 diaper (urine only) = 25 mL; and 1 diaper (stool only) = 20 mL. What is the total 8 hour output for this child?

ANS:

160

160 mL

Total emesis output = 85 mL and total urine and stool output = 75 mL. These are added together to get the total output for the 8 hours = 160. Emesis, urine, and stool are all counted when totaling output.

DIF: Cognitive Level: Application REF: p. 339

OBJ: Nursing Process Step: Evaluation MSC: Physiological Integrity