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A nurse is assessing a 7-year-old who has been diagnosed with acute pyelonephritis, what assessment finding requires immediate action by the nurse?

A.

Blood pressure of 136/92 mg

B.

Heart rate of 100 bpm

C.

Decreased urine output

D.

Tea-colored urine

Answer and Explanation

The Correct Answer is A

A. Hypertension (blood pressure of 136/92 mm Hg) in a child with acute pyelonephritis can indicate a severe condition that may lead to renal damage or worsening kidney function. Immediate intervention is necessary to manage high blood pressure and prevent complications.

B. A heart rate of 100 bpm is within normal limits for a 7-year-old and does not require immediate action.

C. Decreased urine output is concerning and needs monitoring, but hypertension is the more urgent issue.

D. Tea-colored urine suggests hematuria or concentrated urine, which is important but not as immediately life-threatening as high blood pressure.


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Related Questions

Correct Answer is C

Explanation

A. Tender inguinal lymph nodes are not associated with celiac disease and are more indicative of localized infections or lymphadenopathy.

B. An enlarged liver is not typically related to celiac disease but may occur in other conditions such as fatty liver disease.

C. A protuberant abdomen is a common finding in children with celiac disease due to malabsorption and gas accumulation in the intestines. This is often accompanied by abdominal distension and discomfort.

D. Periorbital edema is not characteristic of celiac disease and is more commonly seen in conditions like nephrotic syndrome.

Correct Answer is A

Explanation

A. Activities should be tailored to the child’s developmental level, as children with spastic cerebral palsy may have delays in reaching developmental milestones.

B. Corticosteroids are not typically used for cerebral palsy, as it is a non-progressive condition affecting motor function, not an inflammatory condition.

C. Cerebral palsy is non-progressive, meaning it does not worsen over time, though the muscle tightness (spasticity) may change as the child grows.

D. While prenatal screening can detect certain risk factors, it cannot predict the occurrence of cerebral palsy with certainty.

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