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 A
Explanation
A. "My son might complain of feeling shaky when he has a low blood glucose level."
Explanation: Correct Choice. Shaking or feeling shaky is a common symptom of low blood glucose levels, also known as hypoglycemia. When blood sugar drops too low, the body releases adrenaline, causing shaking or trembling. This response is indicative of an understanding of hypoglycemia symptoms.
B. "My son might have nausea and vomiting with hypoglycemia."
Explanation: Nausea and vomiting are not typical symptoms of hypoglycemia (low blood sugar). They are more commonly associated with hyperglycemia (high blood sugar) or other conditions. This statement is not accurate in the context of hypoglycemia.
C. "Sweating can occur with hyperglycemia."
Explanation: Sweating is more commonly associated with hypoglycemia (low blood sugar) rather than hyperglycemia (high blood sugar). When blood sugar levels drop too low, the body can respond with sweating as part of the adrenaline release. Sweating is not a typical symptom of hyperglycemia.
D. "The onset of low blood glucose usually occurs slowly."
Explanation: The onset of low blood glucose (hypoglycemia) can vary. It can occur suddenly, especially if the individual takes too much insulin or diabetes medication, leading to a rapid drop in blood sugar. The correct understanding is that the onset of low blood glucose can be rapid and not always slow.
Correct Answer is C
Explanation
A. Always infantize the child
Incorrect Explanation: "Infantizing" a child with a growth hormone deficiency is not a relevant or appropriate approach.
Explanation: Growth hormone deficiency is a medical condition that affects a child's growth. Treating the child as an infant could potentially have negative psychological and social effects. It's important to provide appropriate support and understanding without treating the child differently due to their medical condition.
B. Monitor for leukemia
Incorrect Explanation: Monitoring for leukemia is not directly related to growth hormone deficiency.
Explanation: Growth hormone deficiency primarily affects a child's growth and development due to inadequate production of growth hormone. While there might be certain health concerns associated with the condition, monitoring for leukemia is not a common aspect of managing growth hormone deficiency.
C. Help the parents set realistic goals based on the child's age and abilities
Correct Explanation: This is an important aspect to include in teaching.
Explanation: When a child is diagnosed with growth hormone deficiency, it's crucial for parents to set realistic expectations regarding their child's growth. Growth hormone therapy can help, but it's essential to understand that the child's growth might still differ from their peers. Setting realistic goals based on the child's age and abilities can help manage expectations and provide appropriate support.
D. This illness is only seen in males
Incorrect Explanation: Growth hormone deficiency is not limited to males.
Explanation: Growth hormone deficiency can affect individuals of any gender. It is not exclusive to males. The condition results from insufficient production of growth hormone by the pituitary gland, and it can occur in both males and females.
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