A toddler diagnosed with nephrotic syndrome has a nursing diagnosis of excess fluid related to fluid accumulation (generalized edema). Which nursing intervention would be the priority to include in the nursing plan of care?
Seizure Precautions
Ambulation
Daily weight
Keep bed position flat
The Correct Answer is C
A) Seizure Precautions:
While seizure precautions are important in certain clinical situations, they are not directly related to the excess fluid and generalized edema associated with nephrotic syndrome. Nephrotic syndrome is primarily characterized by proteinuria, hypoalbuminemia, and fluid retention, which can lead to edema. Seizure precautions would not directly address the fluid imbalance in this context.
B) Ambulation:
Ambulation involves walking or movement and is not a priority intervention for addressing excess fluid and generalized edema. The primary concern in nephrotic syndrome with fluid accumulation is to manage the fluid balance and prevent further complications related to edema, such as respiratory distress or compromised circulation.
C) Daily weight:
This is the correct priority intervention. Daily weight monitoring is crucial in managing fluid balance and assessing the effectiveness of treatment in a child with nephrotic syndrome and fluid accumulation. Sudden weight gain can indicate worsening edema, while weight loss might indicate a response to treatment. Daily weight monitoring provides essential information to adjust fluid and medication management accordingly.
D) Keep bed position flat:
While maintaining a flat bed position may help improve venous return and fluid distribution, it is not the priority intervention for managing excess fluid and generalized edema in a child with nephrotic syndrome. Monitoring daily weight and adjusting treatment based on weight changes are more directly related to addressing the fluid imbalance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Position the child laterally
Explanation: When a child is experiencing a seizure, it's important to ensure their safety and prevent injury. Positioning the child laterally, also known as the recovery position, helps keep the airway clear and allows any fluids to drain from the mouth, reducing the risk of aspiration. It also helps prevent the child from choking on saliva or vomit.
The other options are not appropriate actions during a seizure:
B. Using a padded tongue blade is not recommended during a seizure. Placing objects in the mouth during a seizure can lead to injury, including damage to the teeth, jaw, or airway.
C. Attempting to stop the seizure is not within the nurse's control. Seizures are caused by abnormal electrical activity in the brain and should not be interrupted forcefully. Instead, the focus should be on ensuring the child's safety and managing the situation until the seizure stops on its own.
D. Restraining the child's arms is not advisable during a seizure. Restraining can cause harm and increase the risk of injury to the child or others involved. It's important to allow the seizure to run its course while protecting the child from harm.
Correct Answer is B
Explanation
A. Maintain a saline-lock:
Maintaining a saline lock is important for potential intravenous access, but it is not the most urgent priority compared to actions that directly monitor the child's condition and help manage the disease.
B. Check the child's daily weight:
Monitoring daily weight is crucial in acute glomerulonephritis, as it helps assess fluid balance and detect early signs of fluid retention or worsening kidney function, which are key concerns in this condition. This makes it a priority action.
C. Place the child on a no-salt-added diet:
While dietary modifications can be important for managing various health conditions, including kidney issues, this is not the top priority in this situation. Reducing salt intake can help manage fluid retention, but it is not the nurse's priority action at this moment.
D. Educate the parents about potential complications:
Patient education is crucial, especially in chronic conditions, but in this acute care scenario, the nurse's immediate priority is to address the child's needs. Educating parents about potential complications should be done, but it's not the most immediate action.
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