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 B
Explanation
A) Low-protein, low-potassium diet:
While low-protein and low-potassium diets can be appropriate for certain kidney conditions, such as chronic kidney disease, they are not typically the primary focus in the acute phase of glomerulonephritis. Protein restriction might be considered if there is significant kidney damage, and potassium levels are elevated.
B) Low-sodium fluid-restricted diet:
This is the most appropriate option. In acute glomerulonephritis, the kidneys' ability to regulate sodium and fluid balance may be impaired due to inflammation and decreased glomerular filtration. Fluid retention and peripheral edema are common. A low-sodium diet helps reduce fluid retention and manage edema.
C) Low carbohydrate, low-protein diet:
Low-carbohydrate and low-protein diets are not the main dietary considerations for acute glomerulonephritis. The primary focus is on managing sodium and fluid intake due to impaired kidney function.
D) Regular diet, no added salt:
A regular diet without added salt might exacerbate the fluid retention and edema associated with acute glomerulonephritis. Sodium intake needs to be controlled to prevent further fluid buildup.
Correct Answer is A
Explanation
A) Heat intolerance.
Explanation: This statement is true. Heat intolerance is a common symptom of hyperthyroidism, including Graves' disease. People with hyperthyroidism often have an overactive thyroid gland that produces an excessive amount of thyroid hormones. This can lead to an increased metabolic rate, which in turn makes them sensitive to heat. They may feel excessively warm, sweat more than usual, and have difficulty tolerating hot weather.
B) Weight gain.
Explanation: This statement is false. Weight gain is not a typical finding in Graves' disease or hyperthyroidism. In fact, one of the hallmark symptoms of hyperthyroidism is unexplained weight loss despite increased appetite. The elevated levels of thyroid hormones cause an increase in metabolism, leading to weight loss.
C) Bradycardia.
Explanation: This statement is false. Bradycardia refers to an abnormally slow heart rate, typically below 60 beats per minute. In hyperthyroidism, the heart rate is often elevated rather than slowed down. The excessive thyroid hormones can lead to an increased heart rate (tachycardia) and palpitations. It's important to note that if the question were about hypothyroidism (underactive thyroid), bradycardia might be more relevant.
D) Lethargy.
Explanation: This statement is false. Lethargy, or a state of extreme tiredness and lack of energy, is more commonly associated with hypothyroidism (underactive thyroid) rather than hyperthyroidism. Hyperthyroidism usually leads to symptoms of increased energy, restlessness, and hyperactivity due to the elevated metabolic rate caused by excess thyroid hormones.
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