A nurse is assisting in the care of a 10-year-old child.
Complete the diagram by dragging from the choices below to specify what condition the child is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the child's progress.
The Correct Answer is []
Rationale for Correct Choices:
- Acute glomerulonephritis: The child’s symptoms, such as dark brown urine (which indicates hematuria), recent history of streptococcal pharyngitis, swelling around the eyes, and slight weight loss — are highly suggestive of acute glomerulonephritis, a kidney condition that can follow a streptococcal infection. Elevated BUN and creatinine levels, along with proteinuria, also support this diagnosis.
- Encourage child to increase fluid intake: Hydration is important in managing acute glomerulonephritis, as it helps prevent further renal damage and supports kidney function. However, fluid intake should be monitored and balanced with any renal impairment and swelling.
- Restrict sodium intake: Sodium restriction is crucial in managing acute glomerulonephritis to prevent fluid retention, which can lead to worsening edema and hypertension. Given the child’s swelling and blood pressure readings, it’s important to minimize sodium intake.
- Monitor urine volume and appearance every shift: Monitoring the urine volume and appearance is key in assessing kidney function and detecting worsening of the child’s condition.
- Obtain daily weight: Daily weight monitoring helps detect fluid retention, which is common in acute glomerulonephritis due to edema. Significant weight changes may indicate worsening of kidney function or fluid balance.
Rationale for Incorrect Choices:
- Acute asthma exacerbation: While the child has a history of asthma and is showing some wheezing and a nonproductive cough, these symptoms are not the primary concern here. The child’s dark urine, swelling, and recent history of streptococcal infection are more consistent with acute glomerulonephritis than an asthma exacerbation.
- Bacterial pneumonia: Pneumonia is not indicated by the child’s symptoms. While the child has a cough and wheezing, the absence of fever, difficulty breathing, and other typical pneumonia symptoms makes this diagnosis unlikely.
- Urinary tract infection: The presence of dark urine, hematuria, and proteinuria, along with a recent streptococcal infection, points more toward acute glomerulonephritis rather than a urinary tract infection.
- Administer bronchodilators: While the child has wheezing, this is not the primary issue, as the main concern is the possible kidney involvement due to acute glomerulonephritis. Bronchodilators would be appropriate for asthma exacerbations but not for managing kidney issues.
- Administer antipyretics: There is no indication of fever at this time, and the primary concern is the renal condition. Antipyretics would only be useful if the child developed a fever.
- Administer an angiotensin-converting enzyme inhibitor : ACE inhibitors are used to treat hypertension and chronic kidney disease, but they are not typically prescribed immediately for acute glomerulonephritis without further evaluation. The child’s blood pressure is slightly elevated but not severely enough to warrant this treatment at this time.
- Monitor peak expiratory flow rate daily: This parameter is useful for monitoring asthma, but it is not relevant for assessing acute glomerulonephritis. The child’s respiratory issues are less concerning than the renal symptoms in this case.
- Obtain temperature every 4 hr: There is no indication that the child has a fever, and thus, temperature monitoring is not as critical as monitoring renal function through urine appearance, volume, and daily weight.
- Monitor oxygen saturation levels every 4 hr: While the child has some respiratory symptoms, the primary issue is related to kidney function. Oxygen saturation monitoring is more appropriate for managing respiratory conditions, not for assessing the severity of acute glomerulonephritis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Administer two puffs of albuterol: Albuterol is a bronchodilator used as a quick-relief (rescue) medication for asthma attacks. It helps to open the airways and alleviate difficulty breathing. The nurse should administer albuterol as directed to help relieve the child’s symptoms.
B. Instruct the child to perform controlled breathing exercises: While controlled breathing exercises can be helpful for managing asthma, they are not the first action during an acute asthma attack. The priority is to use a quick-relief medication like albuterol.
C. Place the child in the supine position: Placing the child in the supine (lying flat) position could worsen breathing difficulty. The child should be placed in an upright position to help facilitate better airflow and reduce breathing distress during an asthma attack.
D. Encourage the use of a flutter mucus clearance device: A flutter mucus clearance device is used to help clear mucus in the lungs, but it is not appropriate for managing acute asthma symptoms. The priority is to administer a bronchodilator to relieve airway constriction.
Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"A"}
Explanation
Rationale for Correct Choices:
- Dextrose 5% in sodium chloride with 20 mEq potassium chloride/L at 75 mL/hr: The prescription for dextrose 5% with potassium chloride at 20 mEq/L should be clarified because the child's potassium level is elevated at 6.2 mEq/L (normal range is 3.4 to 4.7 mEq/L). Administering additional potassium could worsen hyperkalemia, which could lead to dangerous complications like arrhythmias.
- Laboratory values: The child's potassium level is already high, and adding more potassium via IV fluids could increase the risk of severe hyperkalemia. The nurse should clarify this prescription to avoid potential harm.
Rationale for Incorrect Choices:
- Piperacillin and tazobactam 4g IV every 8 hr: This antibiotic is appropriate for treating pneumonia in a child with cystic fibrosis. No issues with laboratory values or contraindications are present in this case, so clarification is unnecessary.
- Dornase alfa 2.5 mg inhalation every day: Dornase alfa is used to break down mucus in the lungs of children with cystic fibrosis, and it is prescribed appropriately for this patient. The child’s current condition and medications do not warrant clarification for this prescription.
- Pancrelipase 8,000 units with meals: Pancrelipase is indicated for the child’s cystic fibrosis to assist with digestion, and the prescribed dosage seems appropriate for the child’s weight and condition.
- Albuterol nebulizer 2.5 mg inhalation every 4 hr: Albuterol is used for airway clearance, which is appropriate for managing the child's respiratory symptoms. No clarification is needed for this prescription based on the current findings.
- Vital signs: While the child's heart rate and temperature are elevated, they are within expected ranges for the child’s condition (fever, pneumonia, and cystic fibrosis). There is no immediate need for clarification of medications based on vital signs alone.
- Scheduled therapapy: The child is scheduled for chest physiotherapy and airway clearance therapy, which are standard treatments for cystic fibrosis and pneumonia. There is no issue with the scheduled therapies that requires clarification of the medications.
- Diet: The child has been prescribed a high-protein, high-fat diet to support nutritional needs, especially important in cystic fibrosis. The diet does not require any clarification in relation to the prescribed medications.
- Pre-existing conditions: The child’s pre-existing condition of cystic fibrosis is already taken into account in the prescribed treatments, and no adjustment is needed based on the conditions present.
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