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

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A. Assume you made a mistake and report out the same head circumference as before.

Incorrect Explanation: Assuming a mistake without taking proper action might not be the best approach.

Explanation: While it's good to consider the possibility of human error, healthcare professionals should prioritize accurate measurements and follow appropriate protocols when discrepancies arise.

B. Take Vital Signs.

Incorrect Explanation: Taking vital signs might not directly address the concern about the head circumference measurement.

Explanation: Vital signs (like heart rate, respiratory rate, blood pressure) are important indicators of a patient's overall health, but they may not directly address the issue of the head circumference measurement discrepancy.

C. Report to the MD/NP/PA in charge of the patient the head circumference that you obtained as well as the patient's current status. Expect that they will also re-measure.

Correct Explanation: This is the best next step.

Explanation: When there's a discrepancy in a critical measurement like head circumference, it's important to communicate this to the responsible healthcare provider (MD/NP/PA). They need to be aware of any changes in the patient's condition and measurements, and they will likely want to re-measure or reassess the situation themselves to ensure accuracy.

D. Move your measuring tape to above the mid-forehead, so that your number matches the findings from the week before.

Incorrect Explanation: Fudging measurements to match previous data is not a professional or ethical approach.

Explanation: Altering measurements to match previous values, especially without proper indication, is not a responsible practice in healthcare. It's essential to ensure accurate and honest documentation.

A. A step-wise approach will be used to reduce the dosage gradually. B. Your child will always suffer seizures C. This is always a hereditary disorder D. Only her male offspring will experience seizures

Correct Answer is A

Explanation

A) A step-wise approach will be used to reduce the dosage gradually.

Explanation:

After a certain period of seizure control, a healthcare provider may consider gradually tapering and discontinuing anti-seizure medications in consultation with the child's neurologist. This is often done in a step-wise manner to monitor the child's condition and minimize the risk of seizure recurrence. Stopping anti-seizure medications abruptly can increase the risk of seizures returning. Therefore, the response provided in option A is the most accurate and relevant to the situation.

The other options are incorrect:

B) Your child will always suffer seizures:

This statement is not accurate, as some children with epilepsy can achieve long-term seizure control with appropriate treatment. Epilepsy management varies from person to person, and many individuals can experience extended periods of seizure freedom.

C) This is always a hereditary disorder:

Epilepsy can have both genetic and non-genetic causes. While there are genetic forms of epilepsy, not all cases are hereditary. Epilepsy can be caused by a variety of factors, including brain injuries, infections, and other medical conditions.

D) Only her male offspring will experience seizures:

Epilepsy does not discriminate based on gender. Both males and females can be affected by epilepsy. This statement is not accurate and does not reflect the reality of epilepsy as a medical condition.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When measuring a 6-month-old baby in the hospital for seizures, the nurse obtains a head circumference that is up 1 cm from the last measurement one week ago. The nurse re-measures and gets the same number What is the best next step?

Correct Answer is C

Explanation

A child with epilepsy has been seizure free for 2 years. A father asks the nurse how much longer the child will need to take the anti-seizure medications. The nurse includes which of the following in the response?

Correct Answer is A

Explanation

An eight-year-old with nephrotic syndrome is pale, lethargic, and has ascites. To determine if the ascites is increasing, the nurse should (chose one best answer):

Evidence has demonstrated that we can do a great deaI to prevent and minimalize the occurence of CTE (Concussion Tramatic Encephalophy), damage due to repetitive head injuries. Which of the answers below are true:

A nurse is assessing a child who has nephrotic syndrome. Which of the following findings should the nurse expect?

A 4-year-old with nephrotic syndrome is experiencing severe periorbital edema. The best measure the nurse could institute to help reduce the periorbital edema is:

A nurse is caring for a child who has acute glomerulonephritis. Which of the following actions is the nurse's priority?

What are the priorites of our care and teaching ifor the patient with reflux? (Select All that Apply.)

A nurse is caring for a child who is experiencing a seizure. Which of the following actions should the nurse take?