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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    Description

    This quiz focuses on the cardiovascular, respiratory, neurological, and hemodynamic responses in pediatric patients. It covers vital sign abnormalities such as tachycardia, bradycardia, and altered mental status. Test your knowledge on the critical signs that indicate potential health issues in infants and children.

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