A nurse is providing home care instructions to the parents of a child who is in the edema phase of nephrotic syndrome. Which of the following instructions should the nurse include in the teaching?

Restrict the child's potassium intake.

Provide quiet activities for the child.

Weigh the child once a week.

Administer acetaminophen to the child daily.

Answer and Explanation

The Correct Answer is B

A. Restrict the child's potassium intake. Potassium restriction is not typically required unless hyperkalemia is present.
B. Provide quiet activities for the child. Edema can cause fatigue, and quiet activities help conserve energy and reduce strain.
C. Weigh the child once a week. Daily weight monitoring is critical to track fluid retention or loss.
D. Administer acetaminophen to the child daily. Acetaminophen is not routinely required unless there is a specific indication, such as fever or pain.

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Correct Answer is D

Explanation

A. Administer IV antibiotics: While urgent, antibiotics can be administered after precautions are in place to ensure safety.
B. Monitor vital signs: Important but not the first action. Vital signs can be monitored after precautions are initiated.
C. Encourage oral fluids: Incorrect because IV fluids are usually required due to the severity of the illness and risk of shock.
D. Initiate droplet precautions. Protecting others from transmission is the highest priority in managing bacterial meningitis, a highly contagious condition.

A. Generalized muscle weakness noted in bilateral lower extremities B. Child reports pain in legs on palpation, rates pain as 5 on a scale of 0 to 10 C. Abdomen slightly firm, bowel sounds hypoactive D. Reports last bowel movement was 3 days ago E. Child is awake and alert, responds appropriately to questions

Correct Answer is ["A","B","C","D"]

Explanation

Findings that require immediate follow-up:

Generalized muscle weakness noted in bilateral lower extremities: This could indicate a neurological or muscular issue, such as Guillain-Barré Syndrome (GBS), which is a concern after a viral infection or vaccination. This requires further investigation and close monitoring for any signs of progression, such as worsening weakness or respiratory involvement.
Child reports pain in legs on palpation, rates pain as 5 on a scale of 0 to 10: This pain could be indicative of muscle cramping or weakness, which may be associated with GBS or another neurological condition. Pain in combination with muscle weakness should be followed up closely.
Abdomen slightly firm, bowel sounds hypoactive, and reports last bowel movement was 3 days ago: This could suggest constipation or a gastrointestinal issue. However, the gastrointestinal symptoms may be secondary to the muscle weakness (if part of a systemic condition like GBS), and should be monitored, but it’s not as urgent as the neurological findings.

Findings that do not require immediate follow-up:

Patellar deep tendon reflexes 1+ bilaterally: A 1+ reflex is on the lower end of normal and does not indicate a severe problem by itself.
Child is awake and alert, responds appropriately to questions: This is a reassuring sign and does not require immediate follow-up.

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A nurse is providing home care instructions to the parents of a child who is in the edema phase of nephrotic syndrome. Which of the following instructions should the nurse include in the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Explanation

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