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):
assess the bowel sounds
Frequently ambulate child
Weigh child weekly
monitor and measure the abdominal girth
The Correct Answer is D
A. Assess the bowel sounds:
Bowel sounds are not directly related to the assessment of ascites. Bowel sounds are more relevant in assessing gastrointestinal function and peristalsis. While bowel changes could potentially be a sign of complications, monitoring abdominal girth is more specific to tracking ascites.
B. Frequently ambulate child:
While ambulation is important for overall health, it's not a direct assessment method for monitoring ascites. Ambulating a child might have benefits, but it won't provide specific information about the presence or progression of ascites.
C. Weigh child weekly:
Weekly weighing can provide some information about overall fluid balance, but it might not be as sensitive as measuring abdominal girth when it comes to detecting changes in ascites. Additionally, monitoring weight alone might not give insight into the distribution of fluid in the abdominal cavity.
D. Monitor and measure the abdominal girth.
Explanation: The presence of ascites (accumulation of fluid in the abdominal cavity) in a child with nephrotic syndrome could indicate worsening kidney function and fluid balance. Monitoring and measuring the abdominal girth is a reliable way to assess changes in the amount of fluid accumulation over time. An increase in abdominal girth could suggest a worsening condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Polyuria (excessive urination) is not a symptom of hypoglycemia; it is more commonly associated with hyperglycemia (high blood sugar).
B. Deep rapid respirations are more characteristic of diabetic ketoacidosis (DKA), a complication of uncontrolled diabetes that leads to high blood sugar levels and metabolic acidosis.
C. Dry, flushed skin is not a typical symptom of hypoglycemia; it might be associated with conditions like dehydration or heat exposure, but not with low blood sugar.
D. Tachycardia
Explanation: The symptoms described by the adolescent (feeling shaky, difficulty speaking, difficulty concentrating) along with a blood glucose level of 55 mg/dL indicate hypoglycemia, which is low blood sugar. Tachycardia, or a rapid heart rate, is a common physiological response to hypoglycemia. The body increases the heart rate in an attempt to improve blood flow and deliver glucose to the brain and other vital organs. This is part of the body's fight-or-flight response to low blood sugar.
Correct Answer is ["50"]
Explanation
To calculate the mL of phenytoin oral solution needed for a 250 mg dose, we can use the following equation:
Dose (mg) = Volume (mL) × Concentration (mg/mL)
Given:
Dose = 250 mg
Concentration = 25 mg/5 mL
We need to find the volume (mL):
Volume (mL) = Dose (mg) / Concentration (mg/mL)
Volume (mL) = 250 mg / (25 mg/5 mL)
Volume (mL) = 250 mg / (5 mg/mL)
Volume (mL) = 50 mL
So, the nurse should administer 50 mL of phenytoin oral solution per dose.
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