A nurse is assisting in the planning of care for a client who has acute glomerulonephritis. Which of the following interventions should the nurse recommend including in the plan of care?
Place the client on a low-sodium diet.
Encourage increased fluid intake.
Obtain weekly weight.
Encourage frequent ambulation.
The Correct Answer is A
Choice A reason: A low-sodium diet is essential for clients with acute glomerulonephritis to prevent fluid retention and reduce the workload on the kidneys. This dietary modification helps manage edema and hypertension, common complications of the condition. By limiting sodium intake, the body retains less water, which helps control swelling and blood pressure, making it a crucial intervention in the plan of care.
Choice B reason: Encouraging increased fluid intake is not recommended for clients with acute glomerulonephritis. Excessive fluid intake can lead to fluid overload, worsening edema and hypertension. The kidneys are already compromised in their ability to excrete fluid efficiently, so increasing fluid intake would exacerbate these issues. Instead, fluid intake should be carefully monitored and potentially restricted to prevent further strain on the kidneys.
Choice C reason: Obtaining weekly weight is not specific enough to monitor the acute phase of glomerulonephritis. Daily weights are more appropriate to closely monitor fluid balance and detect changes in edema. Daily weight measurements can help in assessing the effectiveness of interventions such as a low-sodium diet or diuretics and provide timely information for adjusting the plan of care.
Choice D reason: Encouraging frequent ambulation, while generally beneficial for overall health, is not a specific intervention for managing acute glomerulonephritis. The primary focus should be on dietary modifications and monitoring fluid balance to manage symptoms and prevent complications. Ambulation should be encouraged based on the client's overall condition and ability but is not a direct intervention for glomerulonephritis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Stating that "This type of surgery is very easy and should not cause a major disruption in your activities" minimizes the client's concerns and may not be accurate for every individual. Each person's experience with surgery and recovery is unique, and it is important to acknowledge and address the client's specific concerns and reasons for delaying the surgery.
Choice B reason: Saying "Most women don't have any problems during their recovery" is a generalization that may not apply to every client. It does not address the client's individual fears or concerns and may come across as dismissive of their feelings.
Choice C reason: The correct answer is c because asking, "Can you tell me your reasons for delaying the surgery?" shows empathy and allows the client to express their concerns. This opens a dialogue where the nurse can provide information, support, and address any specific issues the client may have about the surgery and recovery process.
Choice D reason: Telling the client, "If this happened to one of my family members, I would tell them to go ahead and not wait," inserts the nurse's personal opinion and may not be helpful to the client. It is important to focus on the client's feelings and concerns rather than offering personal anecdotes or advice.
Correct Answer is B
Explanation
Choice A reason: Actinic keratosis is a rough, scaly patch on the skin caused by long-term sun exposure. It is usually not purplish-brown and is more common in fair-skinned individuals. These lesions are considered pre-cancerous and can develop into squamous cell carcinoma if left untreated. The description of purplish-brown lesions in the context of an AIDS diagnosis is more indicative of Kaposi's sarcoma.
Choice B reason: Kaposi's sarcoma is a type of cancer that forms in the lining of blood and lymph vessels. It often presents as purplish-brown, red, or bluish lesions on the skin or mucous membranes and is commonly associated with AIDS. The multiple, widespread nature of the lesions described aligns with the typical presentation of Kaposi's sarcoma, making it the most likely diagnosis in this scenario.
Choice C reason: Actinic dermatitis, also known as photodermatitis, is an inflammatory reaction of the skin to sunlight. It does not typically present as purplish-brown lesions. This condition manifests as redness, swelling, and possibly blistering in sun-exposed areas. The description given is not consistent with actinic dermatitis and points more towards Kaposi's sarcoma in an AIDS client.
Choice D reason: Basal cell carcinoma does not usually present with multiple, widespread purplish-brown lesions. It is typically a localized lesion that appears as a pearly or waxy bump. The description of multiple, widespread lesions is more characteristic of Kaposi's sarcoma in clients with AIDS, making basal cell carcinoma an unlikely diagnosis in this context.
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