A school-age child with nephrotic syndrome is receiving salt-poor human albumin IV. Which findings indicate to the nurse that the child is manifesting a therapeutic response?
Weight gain of 0.5 kg/day.
Decreased urinary output.
Decreased periorbital edema.
Increased periods of rest.
The Correct Answer is C
Choice A reason: Weight gain of 0.5 kg/day is not a sign of a therapeutic response. It may indicate fluid retention, which is a common complication of nephrotic syndrome. Fluid retention occurs when the kidneys lose protein in the urine, leading to low blood protein levels and reduced oncotic pressure. This causes fluid to leak from the blood vessels into the tissues, resulting in edema and weight gain. The nurse should monitor the child's weight, fluid intake and output, and edema status.
Choice B reason: Decreased urinary output is not a sign of a therapeutic response. It may indicate kidney damage, which is a possible consequence of nephrotic syndrome. Kidney damage occurs when the glomeruli, the filtering units of the kidneys, become inflamed and scarred due to the loss of protein in the urine. This reduces the kidney's ability to filter waste and excess fluid from the blood, resulting in oliguria or anuria. The nurse should measure the child's urine specific gravity, creatinine, and blood urea nitrogen levels.
Choice C reason: Decreased periorbital edema is a sign of a therapeutic response. It indicates that the salt-poor human albumin IV is working to restore the blood protein levels and oncotic pressure. This helps to draw fluid back from the tissues into the blood vessels, reducing the swelling around the eyes and other parts of the body. The nurse should assess the child's skin turgor, capillary refill, and blood pressure.
Choice D reason: Increased periods of rest is not a sign of a therapeutic response. It may indicate fatigue, which is a common symptom of nephrotic syndrome. Fatigue occurs when the body loses protein and energy in the urine, leading to malnutrition and anemia. This causes the child to feel weak, tired, and lethargic. The nurse should provide the child with a high-protein, low-sodium diet, iron supplements, and adequate rest.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Positioning the infant on the stomach occasionally when awake and active is the best response that the nurse can give to the mother. This is because it can help prevent and correct the flat head syndrome, also known as plagiocephaly, by taking pressure off the back of the head and allowing the skull to reshape naturally. It can also promote the infant's motor development and strengthen the neck and shoulder muscles. However, the nurse should also remind the mother to always place the infant on the back when sleeping, as this is the safest position to reduce the risk of sudden infant death syndrome (SIDS) .
Choice B reason: Turning the infant on the left side braced against the crib when sleeping is not a good response that the nurse can give to the mother. This is because it can increase the risk of SIDS, as the infant may roll over to the stomach or suffocate from the bedding or the crib. It can also worsen the flat head syndrome by creating another flat spot on the left side of the head.
Choice C reason: Placing a small pillow under the infant's head while lying on the back is not a good response that the nurse can give to the mother. This is because it can increase the risk of SIDS, as the pillow may cover the infant's face or cause the infant to overheat. It can also interfere with the natural reshaping of the skull and cause neck strain.
Choice D reason: Propping the infant in a sitting position with a cushion when not sleeping is not a good response that the nurse can give to the mother. This is because it can put too much pressure on the spine and the pelvis, which are still developing in the infant. It can also limit the infant's movement and exploration, which are important for learning and development.
Correct Answer is D
Explanation
Choice A reason: Showing indifference to verbal stimulation is not a specific sign of ASD. Some children may have hearing problems, language delays, or other developmental issues that affect their response to verbal cues. However, the nurse should still assess the child's hearing and language skills and refer them to a specialist if needed.
Choice B reason: Having a history of temper tantrums is not a specific sign of ASD. Many children have tantrums as a normal part of their emotional development, especially when they are frustrated, tired, or hungry. However, the nurse should still evaluate the frequency, intensity, and duration of the tantrums and provide guidance to the parents on how to manage them.
Choice C reason: Stroking the hair of a handheld doll is not a specific sign of ASD. This behavior may indicate that the child has a preference for tactile stimulation, which is common among children. It may also show that the child has an attachment to the doll, which is a positive sign of social development.
Choice D reason: Performing odd repetitive behaviors is a specific sign of ASD. These behaviors may include rocking, spinning, hand flapping, lining up objects, or repeating words or sounds. These behaviors are often used by children with ASD to cope with sensory overload, anxiety, or boredom. They may also interfere with the child's learning and social interaction. The nurse should request a follow-up for a possible ASD diagnosis and provide support to the child and the parents.
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