A nurse is caring for a school-age child in the pediatric unit.

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Rationale for correct choices

• Nephrotic syndrome: The child presents with periorbital edema, hypoalbuminemia, hyperlipidemia, proteinuria, and foamy dark urine, classic signs of nephrotic syndrome. The edema fluctuates during the day and laboratory values confirm protein loss. The condition is primarily due to increased glomerular permeability rather than infection or chronic renal disease.

• Encourage a low-sodium diet: A low-sodium diet helps reduce fluid retention and edema associated with hypoalbuminemia. Managing sodium intake supports blood pressure stability and decreases further renal strain. Dietary management complements pharmacologic treatment and promotes comfort by decreasing swelling.

• Administer oral corticosteroids: Corticosteroids are the first-line treatment for nephrotic syndrome, reducing proteinuria and inflammation. Timely administration can induce remission and prevent progression. Steroid therapy also helps normalize serum albumin levels, contributing to improved oncotic pressure and reduced edema.

• Abdominal girth: Monitoring abdominal girth allows early detection of ascites and worsening edema. Progressive increase in girth indicates fluid retention and guides fluid management. This parameter provides a visual and measurable indicator of the child’s response to therapy.

• Urine specific gravity: Urine specific gravity tracks protein loss and hydration status. Elevated values indicate concentrated urine due to proteinuria, which is a hallmark of nephrotic syndrome. Monitoring changes helps assess treatment efficacy and disease progression.

Rationale for incorrect choices

• Acute glomerulonephritis: Typically presents with hematuria, hypertension, and mild proteinuria, often after a recent infection. This child has massive proteinuria and hyperlipidemia, which aligns more with nephrotic syndrome. The edema pattern and labs do not support post-infectious glomerulonephritis.

• Chronic kidney disease: CKD develops over months to years with progressive renal insufficiency, azotemia, and electrolyte imbalances. The child has normal kidney function aside from proteinuria and edema, indicating acute onset rather than chronic progression.

• Hemolytic uremic syndrome: HUS often presents with microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury following diarrhea. Although the child has proteinuria and edema, hemoglobin and platelet counts do not indicate HUS. Lab pattern and history do not support this diagnosis.

• Administer IV antibiotics: There is no evidence of bacterial infection; labs and clinical presentation point to proteinuria from nephrotic syndrome rather than infection. Antibiotics would not address the underlying glomerular pathology.

• Initiate peritoneal dialysis: Renal function is not severely impaired; serum creatinine is not reported elevated. Dialysis is unnecessary in uncomplicated nephrotic syndrome. Conservative management with diet and corticosteroids is appropriate.

• Initiate contact precautions: No infectious etiology is present. Contact precautions are not indicated. The condition is glomerular in origin, not transmissible.

• Abnormal HbA1c: Blood glucose or HbA1c is not relevant; the child does not have diabetes. This parameter does not assess nephrotic syndrome progression.

• Bilirubin: There is no evidence of hemolysis or liver dysfunction; bilirubin is not a relevant parameter. Monitoring bilirubin does not reflect nephrotic syndrome severity.

• Head circumference: Head circumference is not relevant in school-age children for assessing edema or renal disease. Changes in girth relate more to abdominal fluid retention than cranial growth at this age.

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Correct Answer is B

Explanation

A. Fax the client's name and identifiable information to the rehabilitation facility: Faxing client information without encryption or secure transmission can expose sensitive data to unauthorized individuals. This does not fully protect confidentiality under HIPAA regulations.

B. Provide a verbal report of the client's condition to the paramedic performing the transfer: Sharing necessary health information directly with authorized personnel involved in the client’s care is appropriate and protects confidentiality. Verbal handoff ensures the receiving team has critical information while limiting exposure to unauthorized parties.

C. Email the client's health information to the facility in an unencrypted file: Sending unencrypted health information via email is unsafe and violates HIPAA guidelines. Unauthorized access could compromise the client’s privacy and confidentiality.

D. Discuss the client's response to the transfer with another staff nurse: Discussing the client’s health information with staff members not directly involved in the transfer or care constitutes a breach of confidentiality. Only pertinent staff members should receive the information.

A. Temperature 38.2° C (100.8° F) B. Heart rate 104/min C. BP 108/70 mm Hg D. SaO2 97% on room air E. Client reports feeling unwell F. Client states breasts feel firm, heavy, and warm with moderate nipple discomfort while breastfeeding G. Uterus firm at 1 cm above the umbilicus and tender to palpation H. Moderate amount of dark brown, foul-smelling lochia noted I. Surgical incision well approximated with slight edema present; no redness or drainage noted J. WBC count 33,000/mm3 (5,000 to 10,000/mm)

Correct Answer is ["A","B","E","G","H","J"]

Explanation

Rationale for correct choices

• Temperature 38.2° C (100.8° F): A temperature above 38° C after the first 24 hours postpartum is concerning for infection. This client has multiple risk factors including cesarean delivery and prolonged rupture of membranes. Fever in this patient warrants immediate evaluation for postpartum endometritis or mastitis.

• Heart rate 104/min: Tachycardia can indicate a systemic inflammatory or infectious process in the postpartum period. When paired with fever and uterine tenderness, it raises concern for sepsis or worsening uterine infection. Early recognition is critical to prevent complications.

• Client reports feeling unwell: A subjective report of feeling unwell is an important early sign of infection or systemic illness. This symptom, combined with abnormal vital signs and laboratory findings, suggests the client may be developing a postpartum complication requiring prompt intervention.

• Uterus firm at 1 cm above the umbilicus and tender to palpation: Uterine tenderness beyond the immediate postpartum period is abnormal and commonly associated with endometritis. The elevated fundal height also suggests delayed uterine involution, reinforcing concern for uterine infection.

• Moderate amount of dark brown, foul-smelling lochia: Foul-smelling lochia is a classic indicator of postpartum uterine infection. Normal lochia should not have an offensive odor, and this finding strongly supports suspected endometritis requiring immediate follow-up.

• WBC count 33,000/mm³: Although mild leukocytosis is expected postpartum, a WBC count this elevated exceeds normal physiologic changes. In the presence of fever and uterine findings, this level is highly suggestive of an acute infectious process.

Rationale for incorrect choices

• Breasts feel firm, heavy, and warm with moderate nipple discomfort: These findings are consistent with normal breast engorgement during early breastfeeding. While uncomfortable, they are expected postpartum changes and do not indicate infection in the absence of localized redness or systemic signs.

• Surgical incision well approximated with slight edema present: Mild edema without redness, drainage, or separation is a normal postoperative finding. There are no signs suggesting a surgical site infection at this time.

• Respiratory rate 18/min, BP 108/70 mm Hg, SaO₂ 97%: These vital signs fall within expected postpartum ranges and do not indicate acute instability. They do not contribute to the immediate concern for infection or deterioration.

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Naxlex Comprehensive Predictor Exams

A nurse is preparing a client for transfer to a long-term rehabilitation facility following a below-the-knee amputation of the right leg. Which of the following actions should the nurse take to protect the client's confidentiality?

Correct Answer is B

Explanation

Correct Answer is ["A","B","E","G","H","J"]

Explanation

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