EXAM 2 for NURS 414 WSU UPDATED ACTUAL Questions
and CORRECT Anwers
Isotonic dehydration The most common type of dehydration in children and it is when water and
sodium are lost in equal amounts.
Hypotonic dehydration Dehydration where sodium loss exceeds water loss
Hypertonic dehydration Dehydration where water loss exceeds sodium loss
Expected Urine Output According to Age • Infants: 2ml/kg/hour
• Children: 0.5-1 ml/kg/hour
• Adolescents: 40-80 ml/hour
Severity of Dehydration calculation (Normal weight-admission weight) divided by normal weight multiplied by 100
equals percent of dehydration.
Severity of Dehydration ranges • Mild dehydration: 3-5 %
• Moderate dehydration: 6-9%
• Severe dehydration: ≥ 10%
Mild Dehydration: Weight loss 3-5% • May be difficult to detect
• Child may be slightly thirsty
• Child is still alert, fontanel is flat (as expected)
• HR, RR, BP within expected ranges
• Mucous membranes moist, + tears
• Cap refill 2-3 seconds
• Decreased urine output
• The history is important
Moderate Dehydration: Weight loss 6-9% • Moderate thirst
• Irritability, slightly sunken fontanel
• Slightly elevated HR and RR
• Normal to possible orthostatic BP (>10 mmHg change)
• Dry mucous membranes
• Decreased tears, slightly sunken eyes
• Delayed capillary refill 2-4 seconds
• Decreased skin turgor
• Decreased urine output
Severe Dehydration: Weight loss ≥ 10% • Intense thirst
• Excessive irritability, lethargy, sunken fontanel
• Elevated HR and RR, hypotension (orthostatic to shock)
• Change in normal respiratory pattern
• Parched membranes, no tears, sunken eyes
• Capillary refill > 4 seconds
• Cool, mottled skin, poor skin turgor (tenting)
• Little or no urinary output
What is the first intervention for mild-moderate Oral-replacement therapy
dehydration?
, IV fluid replacement formula Replacement fluids = (number representing % of weight loss x 10 mls) x baseline
wt in kg
Gastroenteritis • Inflammation of the GI tract that causes vomiting and diarrhea
• Acute infectious diarrhea caused by virus, bacteria, parasites
Fluid Volume Excess Causes
• Congestive heart failure
• Improper, rapid IV infusion
• Nephrosis
• Adrenal tumors
• Renal failure
Symptoms
• Edema
• Sudden weight gain ( 0.5 kg in one day)
• Bounding pulses
• Distended neck veins
• Enlarged liver
• Orthopnea
• Lung crackles
• Lethargy, seizures, coma
Treatment
• Treat the cause
• Limit intake
• Enhance excretion of
excess fluid
NPASS (Neonatal Pain, Agitation and Sedation Scale) for infants less than 3 months old, 0 to 100 days of age, and 23 weeks gestation
and above
5 assessment criteria:
• Crying/Irritability
• Behavior/State - level of arousal
• Facial expression
• Extremities Tone
• Vital Signs: HR, RR, BP
FLACC behavioral For: infants (at 2 months old) to 4 year olds and
Pain Assessment up to 7 years old in postop
• Face
• Legs
• Activity
• Cry
• Consolability
and CORRECT Anwers
Isotonic dehydration The most common type of dehydration in children and it is when water and
sodium are lost in equal amounts.
Hypotonic dehydration Dehydration where sodium loss exceeds water loss
Hypertonic dehydration Dehydration where water loss exceeds sodium loss
Expected Urine Output According to Age • Infants: 2ml/kg/hour
• Children: 0.5-1 ml/kg/hour
• Adolescents: 40-80 ml/hour
Severity of Dehydration calculation (Normal weight-admission weight) divided by normal weight multiplied by 100
equals percent of dehydration.
Severity of Dehydration ranges • Mild dehydration: 3-5 %
• Moderate dehydration: 6-9%
• Severe dehydration: ≥ 10%
Mild Dehydration: Weight loss 3-5% • May be difficult to detect
• Child may be slightly thirsty
• Child is still alert, fontanel is flat (as expected)
• HR, RR, BP within expected ranges
• Mucous membranes moist, + tears
• Cap refill 2-3 seconds
• Decreased urine output
• The history is important
Moderate Dehydration: Weight loss 6-9% • Moderate thirst
• Irritability, slightly sunken fontanel
• Slightly elevated HR and RR
• Normal to possible orthostatic BP (>10 mmHg change)
• Dry mucous membranes
• Decreased tears, slightly sunken eyes
• Delayed capillary refill 2-4 seconds
• Decreased skin turgor
• Decreased urine output
Severe Dehydration: Weight loss ≥ 10% • Intense thirst
• Excessive irritability, lethargy, sunken fontanel
• Elevated HR and RR, hypotension (orthostatic to shock)
• Change in normal respiratory pattern
• Parched membranes, no tears, sunken eyes
• Capillary refill > 4 seconds
• Cool, mottled skin, poor skin turgor (tenting)
• Little or no urinary output
What is the first intervention for mild-moderate Oral-replacement therapy
dehydration?
, IV fluid replacement formula Replacement fluids = (number representing % of weight loss x 10 mls) x baseline
wt in kg
Gastroenteritis • Inflammation of the GI tract that causes vomiting and diarrhea
• Acute infectious diarrhea caused by virus, bacteria, parasites
Fluid Volume Excess Causes
• Congestive heart failure
• Improper, rapid IV infusion
• Nephrosis
• Adrenal tumors
• Renal failure
Symptoms
• Edema
• Sudden weight gain ( 0.5 kg in one day)
• Bounding pulses
• Distended neck veins
• Enlarged liver
• Orthopnea
• Lung crackles
• Lethargy, seizures, coma
Treatment
• Treat the cause
• Limit intake
• Enhance excretion of
excess fluid
NPASS (Neonatal Pain, Agitation and Sedation Scale) for infants less than 3 months old, 0 to 100 days of age, and 23 weeks gestation
and above
5 assessment criteria:
• Crying/Irritability
• Behavior/State - level of arousal
• Facial expression
• Extremities Tone
• Vital Signs: HR, RR, BP
FLACC behavioral For: infants (at 2 months old) to 4 year olds and
Pain Assessment up to 7 years old in postop
• Face
• Legs
• Activity
• Cry
• Consolability
