A nurse is caring for a 7-year-old child who has acute glomerulonephritis. Which of the following findings is the priority for the nurse to report to the provider?
BP 150/90 mmHg
BUN 20 mg/dL
Urine protein 12 mg/dL
2+ pedal edema
The Correct Answer is A
Choice A reason: A blood pressure reading of 150/90 mmHg is significantly high for a 7-year-old child and indicates hypertension, which can be a serious complication of acute glomerulonephritis. It is a priority to report this finding to the provider as it may require immediate intervention.
Choice B reason: A BUN level of 20 mg/dL is within the normal range for children and is not typically a cause for immediate concern. However, it should be monitored along with other kidney function tests.
Choice C reason: Urine protein of 12 mg/dL is a common finding in acute glomerulonephritis due to increased permeability of the glomerular membrane. It is important but not as urgent as the blood pressure finding.
Choice D reason: 2+ pedal edema is a sign of fluid retention, which is expected in acute glomerulonephritis. While it should be addressed, it is not as immediately concerning as severe hypertension.
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Related Questions
Correct Answer is C
Explanation
Choice A reason: Using a bulb syringe to suction the nares is a common practice for clearing nasal passages in infants, but it is not the primary concern for an infant with a tracheostomy, which requires specific care to maintain airway patency.
Choice B reason: Providing antibiotic therapy may be necessary if there is an infection, but it is not a standard care action for a tracheostomy without evidence of infection.
Choice C reason: Administering intermittent suction via the tracheostomy is essential to clear secretions and maintain airway patency, which is the greatest risk for an infant with a tracheostomy.
Choice D reason: Placing an infant in a prone position to sleep is not recommended due to the increased risk of sudden infant death syndrome (SIDS). Infants should be placed on their backs to sleep.
Correct Answer is C
Explanation
Choice A reason: Explaining procedures in detail to the child can be overwhelming and may not be effective, as children with autism spectrum disorder often have difficulty processing too much verbal information at once.
Choice B reason: Staying with the child for long periods of time is not specific to the care of a child with autism spectrum disorder and does not address their unique needs related to transitions or sensory processing.
Choice C reason: Introducing the child to new situations slowly is important because children with autism spectrum disorder may have difficulty with changes in routine or environment. Gradual introduction can help them adjust and reduce anxiety.
Choice D reason: Giving the child three options when making choices can be helpful, but it is not as critical as introducing new situations slowly. Too many choices can sometimes be overwhelming for children with autism spectrum disorder.
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