Pediatric Vital Signs and Responses

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Questions and Answers

A 5-year-old child presents with persistent vomiting and diarrhea. Which electrolyte imbalance is MOST likely to develop?

  • Hypokalemia
  • Hyperkalemia
  • Hypernatremia
  • Hyponatremia (correct)

A neonate (5 days old) has a sodium level of 128 mmol/L. What is the appropriate interpretation of this lab value?

  • Hypernatremia for a neonate.
  • Normal for a child older than 1 year.
  • Normal for a neonate.
  • Hyponatremia for a neonate. (correct)

Which of the following nursing interventions is MOST appropriate for a child diagnosed with hypernatremia?

  • Encourage a high-sodium diet
  • Administer sodium supplements
  • Restrict fluid intake
  • Administer intravenous fluids (correct)

Which of the following is a potential cause of hypernatremia in children?

<p>Diabetes insipidus (B)</p> Signup and view all the answers

A 10-year-old child is admitted with confusion and muscle weakness. Lab results show a sodium level of 119 mmol/L. Which nursing diagnosis is MOST appropriate?

<p>Electrolyte Imbalance related to Sodium Imbalance (A)</p> Signup and view all the answers

What is the expected normal range of potassium for a 3-year-old child?

<p>3.5-5.5 mmol/L (C)</p> Signup and view all the answers

A child is diagnosed with Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH). Which electrolyte imbalance is the MOST likely complication?

<p>Hyponatremia (A)</p> Signup and view all the answers

A 7-year-old child is receiving intravenous fluids at an excessive rate. Which electrolyte imbalance is the child at risk of developing?

<p>Hyponatremia (B)</p> Signup and view all the answers

Which of the following electrolyte imbalances is most directly associated with milk-alkali syndrome?

<p>Excessive calcium intake (C)</p> Signup and view all the answers

A patient with metabolic alkalosis exhibits compensatory hyperventilation. What is the primary physiological purpose of this response?

<p>To decrease carbon dioxide levels in the blood (A)</p> Signup and view all the answers

Which of the following nursing interventions is most appropriate for a patient experiencing moderate symptoms of metabolic alkalosis?

<p>Monitoring vital signs and electrolyte levels (B)</p> Signup and view all the answers

A patient with a history of cystic fibrosis is admitted with metabolic alkalosis. Which of the following health teachings would be most important for this patient?

<p>Strategies for medication management and recognizing signs of metabolic alkalosis (A)</p> Signup and view all the answers

In a child with respiratory acidosis due to impaired gas exchange, which compensatory mechanism would the nurse expect to observe?

<p>Kidney retention of bicarbonate (B)</p> Signup and view all the answers

A child with muscular dystrophy develops respiratory acidosis. Which of the following etiological factors is the most likely cause in this scenario?

<p>Neuromuscular disorders (A)</p> Signup and view all the answers

Which of the following sets of signs and symptoms would indicate a move from mild to moderate respiratory acidosis?

<p>Dyspnea, tachypnea, cardiac arrhythmias (C)</p> Signup and view all the answers

A child aspirates a foreign body, leading to airway obstruction and subsequent respiratory acidosis. Which of the following physiological processes primarily contributes to the acidosis?

<p>Carbon dioxide accumulation (C)</p> Signup and view all the answers

What nursing intervention is most important when caring for a child with hypermagnesemia?

<p>Administering medications to lower magnesium levels. (C)</p> Signup and view all the answers

A child with a magnesium imbalance is also displaying muscle weakness. Which nursing diagnosis is most appropriate for this?

<p>Activity Intolerance related to muscle weakness (A)</p> Signup and view all the answers

A child is diagnosed with hypochloremia secondary to cystic fibrosis. Besides administering prescribed medications, what dietary advice should the nurse provide to the parents?

<p>Increase the intake of chloride-rich foods like bananas and avocados. (D)</p> Signup and view all the answers

Which assessment finding in a child would lead the nurse to suspect hyperchloremia?

<p>Signs of dehydration with decreased urine output. (D)</p> Signup and view all the answers

Why does hypochloremia lead to metabolic alkalosis?

<p>The kidneys retain bicarbonate ions to compensate for low chloride, raising the pH. (A)</p> Signup and view all the answers

A child presents with muscle weakness, fatigue, and a history of frequent vomiting. Lab results indicate low chloride levels. Which acid-base imbalance is most likely occurring?

<p>Metabolic alkalosis (C)</p> Signup and view all the answers

Parents of a child with a magnesium imbalance ask how to recognize signs of an imbalance at home. What information is most important for the nurse to include in the teaching?

<p>Observe for changes in muscle strength, reflexes, and any signs of cardiac arrhythmias. (C)</p> Signup and view all the answers

How does hyperchloremia contribute to metabolic acidosis?

<p>Excess chloride ions neutralize bicarbonate, decreasing the blood pH. (C)</p> Signup and view all the answers

Which of the following nursing interventions is MOST appropriate for a child experiencing moderate respiratory distress due to bronchiolitis?

<p>Providing high-flow supplemental oxygen and monitoring oxygen saturation. (A)</p> Signup and view all the answers

A child with bronchiolitis is displaying signs of increased anxiety. Which nursing intervention is MOST appropriate to alleviate this?

<p>Educate the child and family about bronchiolitis and its management. (A)</p> Signup and view all the answers

A child with respiratory distress is admitted. Which nursing intervention is the highest priority upon admission?

<p>Ensuring airway patency through suctioning or intubation if needed. (B)</p> Signup and view all the answers

A child is showing mild symptoms of respiratory alkalosis. Which of the following symptoms would the nurse expect to observe?

<p>Rapid breathing and lightheadedness. (D)</p> Signup and view all the answers

Which of the following is the MOST common etiological agent for croup?

<p>Parainfluenza virus (A)</p> Signup and view all the answers

A child with croup is experiencing a barking cough and stridor at rest. Which medication is MOST likely to be administered?

<p>Corticosteroid (D)</p> Signup and view all the answers

The nurse is caring for a child with asthma who is hyperventilating. Blood gas analysis reveals respiratory alkalosis. Which intervention is most appropriate?

<p>Administering a bronchodilator and encouraging slow, deep breathing. (A)</p> Signup and view all the answers

A nursing diagnosis for a child with either bronchiolitis or croup is 'Impaired gas exchange related to inflammation and edema'. Which nursing intervention directly addresses this diagnosis?

<p>Monitoring oxygen saturation and providing oxygen therapy. (A)</p> Signup and view all the answers

A child with cystic fibrosis is at risk for respiratory alkalosis. What health teaching should the nurse prioritize for the family?

<p>Techniques for managing anxiety and stress to prevent hyperventilation. (A)</p> Signup and view all the answers

A child is diagnosed with respiratory alkalosis due to salicylate toxicity. What is the most important nursing intervention?

<p>Implementing measures to enhance salicylate excretion as prescribed and supporting ventilation. (B)</p> Signup and view all the answers

Which health teaching point is MOST crucial for parents of a child recently diagnosed with bronchiolitis or croup?

<p>Recognize signs of respiratory distress and seek prompt medical attention. (A)</p> Signup and view all the answers

A child with respiratory distress has the following arterial blood gas results: pH 7.50, PaCO2 28 mm Hg, HCO3- 22 mEq/L. Which nursing diagnosis is most appropriate?

<p>Acid-Base Imbalance related to respiratory alkalosis. (D)</p> Signup and view all the answers

Which of the following is a modifiable risk factor that parents can manage to reduce the likelihood of their child contracting bronchiolitis or croup?

<p>Exposure to environmental irritants. (C)</p> Signup and view all the answers

A nurse is caring for a child with severe respiratory alkalosis. Which of the following findings requires immediate intervention?

<p>Sudden onset of seizures. (B)</p> Signup and view all the answers

A 6-month-old infant is diagnosed with bronchiolitis. What is the MOST important infection control measure to emphasize to the parents?

<p>Practicing frequent and thorough handwashing. (D)</p> Signup and view all the answers

A child is being discharged after treatment for respiratory alkalosis. Which statement indicates that the parents understand the discharge teaching?

<p>&quot;We will monitor for signs of rapid breathing and encourage slow, deep breaths.&quot; (B)</p> Signup and view all the answers

Which of the following is the most critical nursing intervention for a child diagnosed with intussusception?

<p>Preparing the child for potential enema reduction or surgical intervention. (D)</p> Signup and view all the answers

A nurse is caring for a child with intussusception. Which assessment finding would require immediate notification of the physician?

<p>Signs of shock, such as hypotension and tachycardia. (A)</p> Signup and view all the answers

Which of the following nursing diagnoses takes highest priority in the care of an infant with suspected meningitis?

<p>Risk for injury related to increased intracranial pressure. (A)</p> Signup and view all the answers

What is the primary goal of nursing interventions for a child with meningitis?

<p>Minimizing neurological complications (B)</p> Signup and view all the answers

Which nursing intervention is most important when caring for a child with meningitis?

<p>Monitoring neurological status frequently. (B)</p> Signup and view all the answers

A 10-month-old infant presents with fever, irritability, and vomiting. The mother reports a recent episode of diarrhea. Which condition should the nurse prioritize in their assessment?

<p>Meningitis (B)</p> Signup and view all the answers

Which intervention would be most appropriate for a child experiencing abdominal pain related to intussusception?

<p>Administer pain medication as prescribed. (B)</p> Signup and view all the answers

Following a successful enema reduction for intussusception, what is the most important nursing action?

<p>Monitor for the passage of normal brown stool. (D)</p> Signup and view all the answers

Flashcards

Normal Sodium Levels

Normal sodium (Na+) levels in children are 135-145 mmol/L.

Normal Potassium Levels

Normal potassium (K+) levels in children are 3.5-5.5 mmol/L.

Hyponatremia

Hyponatremia is low sodium in the blood, affecting fluid balance and function.

Hypernatremia

Hypernatremia is high sodium in the blood, leading to dehydration.

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Symptoms of Hyponatremia

Signs include headache, nausea, seizures, and confusion.

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Symptoms of Hypernatremia

Signs include thirst, dry mouth, and dark urine.

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Nursing Intervention for Hypernatremia

Intervene by monitoring sodium, administering fluids, and restraining sodium intake.

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Nursing Diagnoses for Electrolyte Imbalance

Includes electrolyte imbalance, fluid volume deficit, and risk for seizures.

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Hypokalemia

Potassium depletion in the body.

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Hypocalcemia

Calcium depletion in the body.

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Milk-alkali syndrome

Condition due to excessive calcium intake.

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Respiratory alkalosis

pH imbalance due to hyperventilation.

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Signs of metabolic alkalosis (mild)

Fatigue, weakness, headache, nausea, muscle cramps.

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Moderate symptoms of alkalosis

Confusion, seizures, cardiac arrhythmias.

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Nursing interventions for alkalosis

Monitor vital signs, administer fluids and electrolytes.

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Respiratory acidosis

Condition where lungs fail to remove CO2, causing acid buildup.

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Monitor Magnesium Levels

Keep track of magnesium levels in patients to identify imbalances.

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Hypomagnesemia

A condition characterized by low magnesium levels in the body.

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Hypermagnesemia

A condition resulting from excess magnesium in the body.

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Chloride Imbalance

Abnormal chloride levels affecting fluid balance and muscle function.

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Hypochloremia

A deficiency of chloride in the blood.

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Hyperchloremia

An excess of chloride in the blood, often linked to dehydration.

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Signs of Magnesium Imbalance

Symptoms include muscle weakness, fatigue, and seizures for hypomagnesemia.

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Dietary Modifications for Magnesium

Including dark leafy greens and nuts for hypomagnesemia management.

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Respiratory Failure

A condition where the body cannot maintain adequate gas exchange, leading to oxygen deficiency.

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Nursing Management: Assess Respiratory Status

Monitoring vital signs and oxygen saturation to evaluate respiratory efficiency.

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Airway Patency

Ensuring that the airway is clear for oxygen to reach the lungs, sometimes requiring suctioning or intubation.

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Signs of Respiratory Acidosis

Symptoms indicating an accumulation of CO2 and decreased pH, such as confusion and lethargy.

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Respiratory Alkalosis Etiology

Causes of respiratory alkalosis include hyperventilation, panic, and certain medications.

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Signs of Respiratory Alkalosis

Mild symptoms include rapid breathing, lightheadedness, and tingling in fingers and toes.

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Health Teaching: Recognizing Respiratory Issues

Educating patients on signs of respiratory conditions and importance of follow-up care.

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Intussusception

A medical condition where one intestinal segment invaginates into another, causing obstruction.

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Signs of Intussusception

Classic signs include abdominal distention, pain, and vomiting, especially in children.

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Symptoms: Classic Triad

Fever, headache, and stiff neck in children indicate a possible case of meningitis.

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Causes of Meningitis

Meningitis can be caused by bacteria, viruses, or fungi, affecting the brain and spinal cord membranes.

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Nursing Interventions for Intussusception

Monitor vital signs, provide pain management, and prepare for diagnostic testing or surgical intervention.

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Potential Complications of Intussusception

Can lead to perforation, peritonitis, and sepsis if not treated properly.

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Classic Symptoms of Meningitis in Infants

In infants, symptoms include fever, irritability, refusal to feed, and vomiting.

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Nursing Interventions for Meningitis

Assess vital signs, monitor ICP, provide oxygen therapy to manage symptoms.

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Signs of Mild Respiratory Distress

Mild symptoms include runny nose, cough, fever, and wheezing.

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Signs of Moderate Respiratory Distress

Moderate signs include respiratory distress, tachypnea, retractions, and nasal flaring.

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Signs of Severe Respiratory Distress

Severe symptoms include apnea and bradycardia, indicating critical status.

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Nursing Interventions for Respiratory Distress

Key interventions include assessing status, monitoring oxygen, providing therapy, and ensuring nutrition.

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Health Teaching for Bronchiolitis

Teach to recognize bronchiolitis signs, ensure hygiene, avoid contact, and promote vaccination.

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Croup Definition

Croup is an acute viral respiratory illness with larynx, trachea, and bronchi inflammation.

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Etiology of Croup

Caused primarily by viruses like parainfluenza, influenza, and RSV, also can include allergies and irritants.

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Nursing Interventions for Croup

Interventions include assessing respiratory status, providing oxygen therapy, and managing fever and hydration.

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Study Notes

Cardiovascular Responses

  • Tachycardia: Increased heart rate (greater than 160 bpm in infants, greater than 120 bpm in children).
  • Bradycardia: Decreased heart rate (less than 80 bpm in infants, less than 60 bpm in children).
  • Hypotension: Low blood pressure.
  • Cardiac arrhythmias: Abnormal heart rhythms.
  • Decreased cardiac output: Reduced blood flow.

Respiratory Responses

  • Tachypnea: Rapid breathing rate (greater than 40 breaths/minute in infants, greater than 20 breaths/minute in children).
  • Dyspnea: Difficulty breathing.
  • Grunting: Inspiratory effort.
  • Retractions: Chest wall indrawing.
  • Apnea: Pauses in breathing.

Neurological Responses

  • Altered mental status: Confusion, lethargy, or coma.
  • Seizures: Convulsions.
  • Decreased consciousness: Reduced responsiveness.
  • Irritability: Restlessness or agitation.

Hemodynamic Responses

  • Vasoconstriction: Decreased peripheral blood flow.
  • Vasodilation: Increased peripheral blood flow.
  • Increased systemic vascular resistance: Elevated blood pressure.

Renal Responses

  • Oliguria: Decreased urine output (less than 1 ml/kg/h).
  • Anuria: Absent urine output.
  • Fluid overload: Excess fluid accumulation.

Metabolic Responses

  • Metabolic acidosis: Increased lactic acid production.
  • Hypoglycemia: Low blood glucose.
  • Hyperglycemia: Elevated blood glucose.

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