A mother brings her 2-year-old daughter to the clinic with a 2-day his

A mother brings her 2-year-old daughter to the clinic with a 2-day history of a fever of unknown origin.

The mother explains to the nurse that the air conditioning in her apartment is not working and it has been very hot; her daughter has been vomiting for 2 days and has had a fever, and the child is lethargic. The child’s rectal temperature is 101.1° F. The nurse knows the child is probably de-hydrated and should do which of the following first?
1. Give the child some juice to drink.
2. Prepare to start an IV.
3. Get an order for an antipyretic.
4. Sponge the child to bring down the fever.

ANSWER

ANS: 2
Children ages 2 through 12 have less stable regulatory responses to imbalance, and in childhood illnesses they tend to operate within a more narrow range with less tolerance for severe fluid and electrolyte imbalance. Clients who have been exposed to temperature extremes may have clinical signs of fluid and electrolyte alterations. Exposure to environmental temperatures exceeding 28° to 30° C (82.4° to 86° F) results in excessive sweating with weight loss. A body weight loss over 7% decreases the ability of the cooling mechanism to conserve water. The nurse’s first priority is fluid volume replacement, then an antipyretic (because the fever is not dangerously high). If the child has been vomiting, she is likely to vomit the juice.