A nurse is caring for a child who has acute glomerulonephritis.
Which of the following actions is the nurse's priority?
Check the child's daily weight.
Educate the parents about potential complications.
Place the child on a no-salt-added diet.
Maintain a saline lock.
The Correct Answer is A
Nursing care planning goals for a child with acute glomerulonephritis are directed toward the excretion of excess fluid through urination.
Monitoring fluid status is very important and daily weights are an effective way to monitor fluid retention, as weight gain is the earliest sign of fluid retention.
Choice B, Educating the parents about potential complications, is important but not the nurse’s priority.
Choice C, Place the child on a no-salt-added diet, which may be part of the treatment
plan but is not the nurse’s priority.
Choice D, Maintaining a saline lock, may be necessary for administering medications but is not the nurse’s priority.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
An epiphyseal fracture is a fracture that occurs in the epiphyseal plate, which is the layer of cartilage between the end of a long bone and the start of the bone shaft.
This type of fracture is most common in children and adolescents, as their bones are still growing and the epiphyseal plate is not yet fused to the bone shaft.
Because this is where new bone develops, injuries to this area can cause the plate to close prematurely, jeopardizing bone growth.
Choice B, “Bone marrow can be lost through the fracture,” is incorrect because
bone marrow is not lost through an epiphyseal fracture.
Choice C, “The younger the child the longer the healing process will take,” is incorrect because younger children generally heal faster than older children or adults.
Choice D, “The blood supply to the bone is disrupted,” is incorrect because an
epiphyseal fracture does not necessarily disrupt the blood supply to the bone.
Correct Answer is D
Explanation
a.While involving mental health professionals can be part of a broader intervention plan, it is not the immediate priority in cases of suspected abuse. The nurse must first address the immediate safety concerns and follow the required reporting procedures.
b.Separating the child from the parents without proper authority or immediate threat can escalate the situation and may not be legally permissible. This action should be taken by authorities with the legal power to do so if deemed necessary.
c.Nurses are mandated reporters, which means they are legally required to report any suspected child abuse to the appropriate authorities immediately. This action ensures that the child’s safety is prioritized and that a proper investigation can be initiated however,obtaining a detailed history is the priority.
d.When a nurse observes several bruises on a child, the initial action should be toobtain a detailed history. This step allows the nurse to gather information about the circumstances surrounding the bruises, assess for any potential signs of abuse, and determine the most appropriate course of action.
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