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 C
Explanation
A) "Limit fluid intake during mealtime":
Limiting fluid intake during meals is not a standard practice for managing type 1 diabetes. Proper hydration is important for overall health, and fluids should be consumed as needed.
B) "Notify the provider if blood glucose levels are over 350 milligrams/deciliter":
Blood glucose levels over 350 mg/dL can indicate hyperglycemia, which requires prompt attention. High blood glucose levels can lead to complications if not addressed promptly. Contacting the healthcare provider is an appropriate step. However, consistentBlood Glucose Levels Above 240 mg/dL (13.3 mmol/L) or presence of symptoms likefrequent urination, thirst, blurry vision, or fatigue) are concerning. The clientshould have contacted the health care provider by this point.
C) "Test the urine for ketones":
Testing urine for ketones is an important instruction. Ketones are produced when the body breaks down fat for energy, often in the absence of sufficient insulin. High ketone levels can indicate diabetic ketoacidosis (DKA), a serious complication. Regular ketone testing, especially during illness or high blood glucose levels, helps monitor for DKA.
D) "Withhold insulin dose if feeling nauseous":
This instruction is not accurate. Nausea could be a sign of various conditions, including illness. Insulin should not be withheld without consulting a healthcare provider. Managing insulin doses appropriately is crucial to maintaining blood glucose control
Correct Answer is A
Explanation
A. Levothyroxine
Correct Answer: Levothyroxine should be administered before breakfast.
Explanation: Levothyroxine is a synthetic thyroid hormone used to treat hypothyroidism. It needs to be taken on an empty stomach, at least 30 minutes before eating, to ensure proper absorption. Food can interfere with its absorption, especially foods containing calcium, iron, and fiber.
B. Digoxin
Incorrect Explanation: Digoxin does not need to be administered before breakfast.
Explanation: Digoxin is a medication used to treat heart conditions like congestive heart failure and atrial fibrillation. It doesn't have specific instructions regarding administration in relation to meals. It's important to administer digoxin consistently at the same time every day, but it doesn't need to be taken specifically before or after breakfast.
C. Divalproex
Incorrect Explanation: Divalproex does not need to be administered before breakfast.
Explanation: Divalproex is used to treat conditions like epilepsy and bipolar disorder. It can be taken with or without food. While taking it with food might reduce the likelihood of stomach upset, there's no requirement to take it specifically before breakfast.
D. Mycostatin Mouthwash
Incorrect Explanation: Mycostatin mouthwash is not related to breakfast timing.
Explanation: Mycostatin is an antifungal medication used to treat fungal infections in the mouth (oral thrush). Its administration is not linked to meal times. It's typically swished around in the mouth and then swallowed or spit out, depending on the specific instructions provided by the healthcare provider.
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