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 D
Explanation
Choice A reason: The ability to crawl is not the most important assessment for the nurse to obtain. Tay-Sachs disease causes progressive loss of motor skills, so the infant may not be able to crawl or may have regressed from crawling. However, this is not a specific sign of the disease and does not indicate the severity of the condition.
Choice B reason: The eyes with cherry-red spot are not the most important assessment for the nurse to obtain. Tay-Sachs disease causes accumulation of gangliosides in the retina, which results in a cherry-red spot in the center of the macula. However, this is not a specific sign of the disease and does not indicate the severity of the condition.
Choice C reason: The difficulty with swallowing is not the most important assessment for the nurse to obtain. Tay-Sachs disease causes muscle weakness and spasticity, which may affect the infant's ability to swallow. However, this is not a specific sign of the disease and does not indicate the severity of the condition.
Choice D reason: The exaggerated startle reaction is the most important assessment for the nurse to obtain. Tay-Sachs disease causes increased sensitivity to sound and touch, which results in an exaggerated startle reaction. This is a specific sign of the disease and indicates the severity of the condition. The exaggerated startle reaction may also trigger seizures, which can be life-threatening. The nurse should monitor the infant's vital signs, seizure activity, and neurological status closely.
Correct Answer is A
Explanation
Choice A reason: Measuring abdominal circumference provides immediate, objective data about the degree of abdominal distention, which is a key sign of intestinal obstruction in a neonate who hasn’t passed meconium and is vomiting bilious secretions. Establishing a baseline girth measurement guides further assessment, helps detect rapidly worsening distention, and informs decisions about decompression and imaging studies.
Choice B reason: Although initiating an IV infusion is critical for fluid and electrolyte replacement in any vomiting infant, securing intravenous access should follow a focused assessment. Prioritizing assessment ensures you understand the severity of the obstruction and tailor fluid resuscitation and other interventions appropriately.
Choice C reason: Monitoring strict urinary output is not the first action that the nurse should take. This is because urinary output is not the most sensitive indicator of fluid status in infants, especially those with renal insufficiency or oliguria. Monitoring urinary output may also delay more urgent interventions, such as fluid resuscitation and decompression.
Choice D reason: Preparing for anorectal manometry is not the first action that the nurse should take. This is because anorectal manometry is a diagnostic test that measures the pressure and function of the anal and rectal muscles. It is not indicated for infants with suspected meconium ileus, which is a mechanical obstruction of the bowel by thick and sticky meconium. Preparing for anorectal manometry may also delay more urgent interventions, such as fluid resuscitation and decompression.
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