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 B
Explanation
Choice A reason: Having the child blow a cotton ball and have the parent catch it is not a good strategy to ensure the child's cooperation. This activity might distract the child from the assessment and make it difficult for the nurse to listen to the lung sounds.
Choice B reason: Allowing the child to use a stethoscope on a stuffed animal is a good strategy to ensure the child's cooperation. This activity helps the child to understand the purpose of the stethoscope and reduces the fear of the unfamiliar device. It also allows the nurse to observe the child's breathing pattern and chest movement.
Choice C reason: Offering the child bubbles before the stethoscope is placed is not a good strategy to ensure the child's cooperation. This activity might alter the child's breathing pattern and interfere with the accuracy of the assessment.
Choice D reason: Placing a toy in the child's hands while listening to the breath sounds is not a good strategy to ensure the child's cooperation. This activity might distract the child from the assessment and make it difficult for the nurse to listen to the lung sounds.
Correct Answer is D
Explanation
Choice A reason: Instructing the mother to feed the infant nothing for 30 minutes after giving the iron drops is not a correct intervention. It may cause the infant to become hungry, fussy, or dehydrated. It may also interfere with the absorption of iron, as food can enhance the bioavailability of iron in the body.
Choice B reason: Suggesting placing the iron drops in the orange juice and then feeding the infant is not a correct intervention. It may alter the taste and color of the orange juice, making it less palatable for the infant. It may also reduce the potency of the iron drops, as iron can react with the citric acid and vitamin C in the orange juice and form insoluble complexes.
Choice C reason: Telling the mother to follow the iron drops with infant formula instead of orange juice is not a correct intervention. It may decrease the absorption of iron, as calcium and casein in the infant formula can bind with iron and form insoluble complexes. It may also increase the risk of gastrointestinal side effects, such as constipation, nausea, or vomiting.
Choice D reason: Giving the mother positive feedback about the way she administered the medication is a correct intervention. It reinforces the mother's behavior and encourages her to continue giving the iron drops as prescribed. It also acknowledges the mother's efforts and shows respect and appreciation. Following the iron drops with orange juice is a good practice, as vitamin C in the orange juice can enhance the absorption of iron in the body.
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