A nurse is planning care for a client who has acute glomerulonephritis. Which of the following interventions should the nurse include in the plan?
Administer antibiotics.
Encourage increased fluid intake.
Encourage frequent ambulation.
Obtain weight weekly.
The Correct Answer is A
Choice A Reason:
Administering antibiotics is a primary intervention for AGN when it is caused by a bacterial infection, such as post-streptococcal glomerulonephritis. Antibiotics help eliminate the infection and prevent further damage to the glomeruli.
Choice B Reason:
Encouraging increased fluid intake is not typically recommended for AGN, especially if the client has oliguria or edema, which are common in this condition. Fluid intake may need to be restricted to prevent fluid overload and worsening of hypertension.
Choice C Reason:
Frequent ambulation is not a priority intervention for AGN. While maintaining mobility is important, it does not directly address the renal inflammation or potential complications associated with AGN.
Choice D Reason:
Obtaining weight weekly is important for monitoring fluid status, but it is not the primary intervention. Daily weight measurements are more indicative of fluid retention or loss and are essential for closely monitoring the client's fluid balance.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Venous insufficiency can contribute to the development of chronic wounds, particularly in the lower extremities. It is characterized by the inability of the veins to adequately return blood from the legs back to the heart, which can lead to pooling of blood and increased pressure in the veins. This can cause skin changes and ulcers, particularly around the ankles.
Choice B reason:
Malnutrition is indeed a systemic cause of chronic wounds. Adequate nutrition is essential for wound healing, as it provides the necessary proteins, vitamins, and minerals that play a crucial role in the repair process. Protein-energy malnutrition, deficiencies in vitamins C and D, zinc, and other nutrients can impair wound healing and lead to chronic wounds.
Choice C reason:
Infection is typically a local rather than a systemic cause of chronic wounds. While systemic infections can affect wound healing, local wound infections are more directly responsible for delayed healing and the chronicity of wounds. Bacteria can colonize the wound and impede the healing process, leading to a chronic wound.
Choice D reason:
Continued pressure, much like infection, is generally a local cause of chronic wounds. It is most commonly associated with the development of pressure ulcers in individuals who are bedridden or have limited mobility. The constant pressure on certain areas of the body can lead to tissue ischemia and necrosis, resulting in a chronic wound.
Correct Answer is D
Explanation
Choice A reason: Positive Trousseau's sign
Trousseau's sign is indicative of hypocalcemia, not CTS. It is elicited by inflating a blood pressure cuff on the upper arm to above systolic pressure for 3 minutes. A positive sign is characterized by carpal spasm, which is not related to CTS.
Choice B reason: Cool extremities
Cool extremities can be a result of various conditions, including peripheral vascular disease or hypothyroidism. They are not a specific indicator of CTS, which primarily affects nerve function rather than blood circulation or temperature regulation.
Choice C reason: Decreased radial pulse
A decreased radial pulse is not typically associated with CTS. It may indicate a cardiovascular issue or a blockage in the radial artery, which would require further investigation unrelated to CTS.
Choice D reason: Positive Phalen's sign
Phalen's sign is a diagnostic test for CTS. The test is performed by having the patient flex their wrist maximally and hold the position for about 60 seconds. A positive Phalen's sign, which includes numbness and tingling in the thumb, index finger, middle finger, and the radial half of the ring finger, is indicative of CTS. This occurs due to increased pressure on the median nerve when the wrist is in flexion.
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