A nurse is collecting data from a child who has acute glomerulonephritis.
Which of the following findings should the nurse expect?
Decreased blood pressure
Pale yellow urine
Periorbital edema
Increased urination
The Correct Answer is C
c. Periorbital edema.
Explanation: Acute glomerulonephritis is an inflammatory condition affecting the glomeruli of the kidneys. It is commonly characterized by periorbital edema, which is swelling around the eyes. This occurs due to fluid retention and impaired kidney function. Other common manifestations of acute glomerulonephritis include hypertension (increased blood pressure), dark or tea-colored urine (hematuria), decreased urine output, and signs of fluid overload such as edema in the hands, feet, and face.
Option a, decreased blood pressure, is not typically seen in acute glomerulonephritis. Instead, hypertension is a common finding due to fluid retention and increased blood volume.
Option b, pale yellow urine, is not expected in acute glomerulonephritis. Instead, urine may appear dark or
tea-colored due to the presence of blood (hematuria).
Option d, increased urination, is not a characteristic finding in acute glomerulonephritis. Instead, there is often a decrease in urine output or oliguria.
It is important to note that individual presentations may vary, and the nurse should consider the complete clinical picture and the child's specific symptoms when assessing for acute glomerulonephritis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
c. "I will have a chest x-ray following the procedure."
Explanation:
The statement that indicates an understanding of the information provided is "I will have a chest x-ray following the procedure."
Explanation for the other options:
a. "I will have general anesthesia during the procedure":
This statement is incorrect. Thoracentesis is typically performed using local anesthesia, which numbs the area where the needle will be inserted. General anesthesia, which induces a state of unconsciousness, is not usually required for this procedure.
b. "I will lie flat for 6 hours following the procedure":
This statement is incorrect. While the client may be advised to lie still for a short period after the thoracentesis, it is not necessary for them to lie flat for a full 6 hours. The specific post-procedure instructions may vary depending on the client's condition and the healthcare provider's preferences.
d. "I will breathe deeply through my nose during the procedure":
This statement is incorrect. During a thoracentesis, the client is typically asked to sit upright and lean forward to allow beter access to the space between the lungs and chest wall. They may be instructed to take slow, deep breaths and hold their breath for short periods as needed during the procedure to help maintain proper positioning and reduce the risk of complications.
In summary, the statement that demonstrates an understanding of the thoracentesis procedure is "I will have a chest x-ray following the procedure." This indicates the client's awareness of the need for a post- procedure chest x-ray to evaluate the results and ensure the absence of any complications.
Correct Answer is C
Explanation
c. Hallucination
In the scenario described, the client's experience of receiving special audible messages from the Central Intelligence Agency that no one else can hear indicates a hallucination. Hallucinations are perceptual disturbances in which a person experiences sensory perceptions without any external stimuli. They can occur in any sensory modality, such as hearing (auditory hallucinations), seeing (visual hallucinations), smelling (olfactory hallucinations), tasting (gustatory hallucinations), or feeling (tactile hallucinations).
In this case, the client is experiencing auditory hallucinations, as he is perceiving auditory stimuli (audible messages) that are not present in the external environment. Auditory hallucinations are most commonly associated with schizophrenia, although they can occur in other psychiatric disorders as well.
Derealization (option a) refers to a subjective feeling of unreality or detachment from the environment. It involves a perception that the external world is strange, distorted, or unreal. This is not the primary alteration in perception described in the scenario.
Illusion (option b) is a misinterpretation or misperception of a real sensory stimulus. It occurs when a person's perception of an actual stimulus is distorted or misunderstood. There is no indication of a misperception of a real stimulus in the scenario.
Depersonalization (option d) is a subjective experience of being detached from one's own body, thoughts, or emotions. It involves a feeling of being outside of oneself or observing oneself from a distance. This is not the primary alteration in perception described in the scenario.
Therefore, the correct answer is c. Hallucination, as the client's experience of receiving special audible messages that no one else can hear represents an auditory hallucination.
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