The nurse is caring for a ten-year-old diagnosed with gastroenteritis
Item 1 of 1
- Nurses’ Note
1234: The client’s parents indicate that he has been vomiting for the past twelve hours and has been unable to keep any fluids or foods down. The client's parents report that a similar illness has circulated in his school for several weeks. The assessment showed a child who was lethargic and fully oriented. The skin was hot, and the eyes appeared sunken. Capillary refill time was > 2 seconds. The client was communicative and reported no pain. Bowel sounds were active in all four quadrants, with no pain endorsed upon palpation. The client has no known medical history, is up to date with all immunizations, and takes no medications.
- Vital Signs
Temperature 100.4° F (38° C)
Pulse 101/minute
Respirations 14/minute
Blood Pressure 100/70 mm Hg
Pulse oximetry 97% on room air
Based on the client assessment, the nurse should plan to take which actions? Select all that apply
Based on the client assessment, the nurse should plan to take which actions? Select all that apply
Statistics
Subject/Lesson
Subject
Child Health
Lesson
Gastrointestinal
Client Need
Test Plan
Physiological Adaptation
Related Topic
Alterations in Body Systems
Item Type
Item Type
GenerateSolutions
Explanation
- The assessment indicates that the client is dehydrated. Interventions for the dehydrated client include instructing the client to avoid sweetened drinks, as these drinks cause further dehydration.
- Considering the significant dehydration, parenteral (IV) hydration is likely with isotonic saline. Obtaining a physician's order to insert a vascular access device is appropriate. Once the client has received fluids and potentially a prescribed anti-emetic, it would be reasonable to have the client attempt a PO (by mouth) challenge, where the client is given clear liquids to see if they can hold it down without vomiting.
- Measuring the abdominal circumference is unnecessary, as this would be an intervention for a client with ascites.
- Nasogastric tube insertion, initiating a 24-hour urine collection, and providing a mask to the parents would not be necessary. The nurse should monitor the client's urine output, but a 24-hour urine specimen collection is unnecessary.
- To prevent the transmission of viral gastroenteritis, contact precautions should be initiated with an emphasis on thorough hand hygiene and the disinfection of common surfaces in the home.
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2 Key Topics
Fluid Volume Deficit
