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 C
Explanation
A. Latex gloves: Latex gloves should be avoided, especially in newborns, due to the risk of allergic reactions. Non-latex gloves are the preferred option for any care involving newborns.
B. Soft restraints: Soft restraints are not necessary for the care of a newborn with a myelomeningocele unless there is a specific concern for the infant’s safety. Restraints should not be routinely used unless deemed absolutely necessary.
C. Sterile saline: Sterile saline is essential for cleaning and maintaining the integrity of the myelomeningocele sac. The sac should be kept moist with sterile saline to prevent it from drying out or becoming infected. This is a critical to have at the bedside for proper care.
D. Rectal thermometer: A rectal thermometer should be avoided in infants with a myelomeningocele, especially if the sac involves the lower spinal cord, as it can potentially cause injury to the delicate tissue or result in a risk of infection.
Correct Answer is []
Explanation
Rationale for Correct Choices:
- Lead poisoning: The child's exposure to construction dust in a home built in the 1950s, coupled with symptoms like lethargy, irritability, weakness, and abdominal discomfort, suggests lead poisoning. Lead exposure in older homes with construction dust is a significant risk factor.
- Reinforce education on lead exposure and prevention: Given the suspected lead exposure, educating the parents about how to reduce the child’s exposure to lead is crucial. This includes steps like avoiding dust, cleaning thoroughly, and taking preventive measures to protect the child.
- Prepare to assist with chelation therapy: If lead poisoning is confirmed, chelation therapy is the mainstay treatment to help remove lead from the body. Chelation agents bind to lead in the body, facilitating its excretion.
- Blood lead levels: Monitoring blood lead levels is essential for confirming lead poisoning and determining the severity of the exposure. Elevated blood lead levels would guide the need for chelation therapy.
- Developmental milestones: Lead poisoning can adversely affect cognitive, motor, and developmental growth in children. Monitoring developmental milestones is critical to assess if lead exposure is impacting the child’s growth and development.
Rationale for Incorrect Choices:
- Meningitis: Although the child has had exposure to meningitis, the clinical presentation does not align with typical meningitis, which often presents with more acute symptoms like fever, nuchal rigidity, and altered consciousness.
- Guillain-Barré Syndrome: Guillain-Barré syndrome is unlikely as it typically presents with ascending paralysis. The child’s symptoms, such as irritability and weakness, are more consistent with lead poisoning, especially with the known risk factors of lead exposure.
- Diabetes mellitus type 1: While the child shows increased thirst and urination, the overall presentation of irritability, abdominal discomfort, and weakness, along with the known risk of lead exposure, makes lead poisoning a more likely diagnosis.
- Assist with lumbar puncture: A lumbar puncture is typically performed to diagnose meningitis or other central nervous system infections. The child’s symptoms do not suggest meningitis, and this action is not warranted at this time.
- Glycosylated hemoglobin (HbA1c): Monitoring HbA1c is useful for diagnosing diabetes, but it is not appropriate for assessing lead poisoning. Blood glucose levels would be more relevant to diagnose diabetes type 1, but in this case, lead poisoning is the primary concern.
- Assist with administration of intravenous immunoglobulin: Intravenous immunoglobulin (IVIG) is generally used to treat autoimmune disorders or infections, such as Guillain-Barré syndrome. It is not appropriate for lead poisoning, which requires chelation therapy.
- Nuchal rigidity: There is no indication of neck stiffness or signs of meningitis. Nuchal rigidity would be relevant in the case of suspected meningitis, but this is not the primary diagnosis here. The child’s symptoms align more with lead poisoning.
- Electromyography results: Electromyography is typically used to assess nerve function in conditions like Guillain-Barré syndrome, but it’s not necessary for diagnosing or managing lead poisoning.
- Obtain a serum blood glucose: While obtaining a blood glucose is important to rule out diabetes type 1, the child’s symptoms, coupled with the lead exposure risk, are more aligned with lead poisoning.
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