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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason: Squamous cell carcinoma commonly occurs on sun-exposed areas such as the face, ears, neck, and hands, but not necessarily the trunk. It is important to emphasize the role of sun exposure in the development of this type of skin cancer.

Choice B reason: Radiation therapy is used in the treatment of certain types of skin cancer, but it is not typically the first choice for metastatic skin cancer. Other treatments, such as surgery, immunotherapy, or targeted therapy, are often preferred depending on the type and stage of skin cancer.

Choice C reason: The correct answer is c because sun exposure, especially during childhood, significantly increases the risk of developing skin cancer later in life. This highlights the importance of sun protection measures from an early age to prevent skin cancer.

Choice D reason: Basal cell carcinoma is the most common and least aggressive type of skin cancer. It rarely metastasizes and is usually slow-growing, making early detection and treatment highly effective.

A. Excessive thrombosis and bleeding. B. Progressive increase in platelet production. C. Immediate sodium and fluid retention. D. Increased clotting factors.

Correct Answer is A

Explanation

Choice A reason: Disseminated intravascular coagulation (DIC) is a condition characterized by both excessive clotting and excessive bleeding. The clotting cascade is inappropriately activated throughout the body, leading to the formation of numerous small blood clots in the blood vessels. These clots consume clotting factors and platelets, which can then lead to excessive bleeding. This paradoxical combination of thrombosis and bleeding is a hallmark of DIC.

Choice B reason: In DIC, platelet consumption exceeds production. The formation of numerous clots uses up platelets faster than they can be produced, which can result in thrombocytopenia and bleeding. Therefore, a progressive increase in platelet production is not an expected finding in DIC.

Choice C reason: Immediate sodium and fluid retention is not a feature of DIC. This condition primarily involves the clotting and bleeding mechanisms, not fluid balance or sodium levels.

Choice D reason: In DIC, clotting factors are consumed in the formation of numerous clots. This leads to a deficiency of clotting factors, contributing to the bleeding tendency seen in this condition. Increased clotting factors would not be expected in a patient with DIC.

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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?

Nursing Test Bank

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