A 4-year-old child with COVID-19 has been experiencing persistent fever, fatigue, and decreased oral intake for the past 3 days. The child's parents report that the child has been drinking small amounts of water but refusing solid foods. Which nursing intervention should be the priority?
1Encourage the child to eat their favorite foods to maintain nutrition
2Administer antipyretic medication to reduce fever and improve appetite
3Monitor fluid balance and assess for signs of dehydration✓ 정답
4Isolate the child completely to prevent transmission to family members
해설
Children with decreased oral intake are at high risk for dehydration due to higher metabolic rates and smaller fluid reserves. Priority is monitoring fluid balance and assessing for signs of dehydration. Other options address nutrition or isolation but do not address the immediate risk of dehydration.
Core Nursing ExplanationKey Concept Analysis: This question assesses the nurse's ability to prioritize care using the ABCs (Airway, Breathing, Circulation) and Maslow's Hierarchy of Needs. The core issue is a pediatric patient with an infectious illness (COVID-19) presenting with fever, fatigue, and decreased oral intake. In children, especially young ones, the combination of fever (increasing insensible fluid loss) and poor intake rapidly leads to Key Point!dehydration, which can compromise circulation and become life-threatening.
Answer Rationale: Key Point! The priority nursing intervention is Monitor fluid balance and assess for signs of dehydration. This is a fundamental circulation and physiological need that must be addressed first. Accurate assessment includes monitoring intake and output (I&O), checking for dry mucous membranes, poor skin turgor, decreased urine output, and sunken fontanelles (in infants). This intervention directly addresses the most immediate and potentially dangerous consequence of the child's symptoms.
Distractor Analysis:
Watch out for confusion! Option ① (Encourage favorite foods) addresses nutrition, which is important but secondary to fluid balance. A dehydrated child may not have the energy or desire to eat, and solid food intake does not correct fluid deficits.
Option ② (Administer antipyretics) is a supportive measure to manage fever and comfort, which may indirectly help with appetite. However, it is a dependent nursing action (requires an order) and does not directly assess or treat the underlying risk of dehydration. Reducing fever is not the priority over assessing for its complications.
Option ④ (Isolate completely) is an important infection control measure, specifically for COVID-19. However, in the context of the presented symptoms (fever, fatigue, decreased intake), the physiological threat of dehydration takes precedence over the transmission risk, which can be managed concurrently with standard and transmission-based precautions. Safety for the patient comes before safety for others.
Related Concepts: This scenario integrates pediatric considerations (higher risk for dehydration), infectious disease management (COVID-19), and fundamental prioritization principles. The nurse must always assess the patient's response to illness and identify the most urgent physiological need.Nursing Clinical Practice GuideClinical Scenario: You are the nurse in a pediatric clinic. A 4-year-old, "Leo," is brought in by his worried parents. He is listless, clinging to his mother, and has dry, cracked lips. His parents say he's had a fever of 102°F (38.9°C) for three days, is only sipping water, and hasn't eaten or had a wet diaper in over 8 hours.
Nursing Intervention Strategy:
1. Immediate Assessment (Priority): Weigh the child (comparison to pre-illness weight is the gold standard for fluid loss). Assess vital signs, focusing on tachycardia and orthostatic hypotension. Perform a focused dehydration assessment: check capillary refill time (>2 seconds is abnormal), skin turgor (tenting), mucous membranes, and fontanelle in infants. Document accurate I&O.
2. Care Planning & Implementation: Based on assessment, the plan may range from encouraging oral rehydration with pediatric electrolyte solutions (e.g., Pedialyte) to initiating IV fluid therapy per physician order for moderate to severe dehydration. Administer antipyretics as ordered to promote comfort and reduce metabolic demand.
3. Patient & Family Education: Teach parents signs of dehydration to watch for at home. Educate on the importance of small, frequent sips of clear fluids or oral rehydration solutions versus large amounts at once. Provide guidance on fever management and when to seek further care.
Patient Safety and Precautions: When encouraging oral fluids, do not force-feed, as this can lead to aspiration. For IV therapy, use a volume-controlled infusion pump and carefully calculate drip rates for pediatric patients to prevent fluid overload. Maintain appropriate isolation precautions (e.g., mask, gown as needed) while providing care.
Nursing Procedure & Medication FlowAssessing for Dehydration in a Child:
Sign
Mild Dehydration
Moderate-Severe Dehydration
Mental Status
Alert, restless
Lethargic, irritable
Mucous Membranes
Slightly dry
Parched, very dry
Tears
Present
Absent
Urine Output
Slightly decreased
Significantly decreased (oliguria)
Capillary Refill
2 seconds
>2-3 seconds
Skin Turgor
Normal or slight tenting
Marked tenting
Medication Note: Antipyretics like Acetaminophen (Tylenol) or Ibuprofen (Advil/Motrin) are given based on weight, not age. Always double-check the dose calculation. Ibuprofen is typically not recommended for dehydrated children due to potential renal risk.
A Word from Your Senior Nurse
"In pediatrics, kids can 'crash' fast. That persistent fever and refusal to drink are huge red flags waving at you. Your first job isn't to get them to eat a chicken nugget or to give Tylenol on a schedule—it's to figure out if they're dry. Are they peeing? Are their lips dry? That assessment tells you if this is a 'watch closely at home' situation or a 'we need an IV now' emergency. Always think circulation first. This mindset saves lives, both on the NCLEX and at the bedside."
Dehydration — A condition resulting from excessive loss of body water and electrolytes, leading to impaired circulatory and metabolic function. In children, it can progress rapidly due to higher metabolic rates and smaller fluid reserves.
Intake and Output (I&O) — The meticulous measurement of all fluids a patient consumes (intake) and all fluids the patient eliminates (output). It is a critical nursing assessment for monitoring fluid balance.
Pediatric Vital Signs — Normal ranges for heart rate, respiratory rate, and blood pressure vary significantly by age in children. Tachycardia is often the earliest sign of dehydration or fever in a child.
Oral Rehydration Therapy — The first-line treatment for mild to moderate dehydration, involving the administration of oral rehydration solutions (ORS) containing specific ratios of glucose and electrolytes to promote intestinal absorption of water.
Transmission-Based Precautions — Infection control measures (Contact, Droplet, Airborne) used in addition to Standard Precautions for patients with known or suspected infections. COVID-19 typically requires Droplet and Contact Precautions (or Airborne per current guidelines).