Patient Data

Exhibits

Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

• Nephrotic syndrome: The child’s rapid weight gain over two months, generalized edema, fatigue with minimal activity, and laboratory findings showing significant proteinuria, hypoalbuminemia, and mild hematuria strongly suggest nephrotic syndrome, which involves increased glomerular permeability and fluid retention.

• Administering intravenous albumin increases plasma oncotic pressure, helping to pull interstitial fluid back into the intravascular space, thereby reducing edema, improving circulatory volume, and supporting perfusion in a child with hypoalbuminemia.

• Provide a low-salt diet: Implementing a low-sodium diet is essential to help manage fluid retention associated with nephrotic syndrome, as excessive sodium intake worsens edema and may contribute to hypertension and further fluid overload.

• Daily weight: Monitoring daily weight provides a sensitive measure of fluid status and the effectiveness of therapeutic interventions, as even small changes in weight can reflect shifts in edema or fluid accumulation.

• Abdominal girth: Measuring abdominal girth regularly allows the nurse to track ascites and fluid accumulation in the peritoneal cavity, which is a common complication of nephrotic syndrome and can indicate worsening disease or inadequate response to therapy.

Rationale for Incorrect Choices:

• Type 1 diabetes: Type 1 diabetes typically presents with hyperglycemia, polyuria, polydipsia, and weight loss, none of which are observed in this child. The presence of edema and proteinuria is not consistent with diabetes.

• Hemolytic uremic syndrome: HUS is characterized by acute kidney injury, microangiopathic hemolytic anemia, and thrombocytopenia. This child does not exhibit hemolysis, platelet abnormalities, or acute renal failure, making HUS unlikely.

• Wilms' tumor: Wilms’ tumor usually presents as a palpable abdominal mass, sometimes with hematuria, but it does not cause generalized edema, proteinuria, or hypoalbuminemia, which are prominent in this child.

• Place the child on strict bed rest: Strict bed rest is unnecessary unless the child’s symptoms are severe. Children with nephrotic syndrome can maintain normal activity levels while under medical monitoring.

• Prepare the child for emergency surgery: Nephrotic syndrome is a medical condition requiring pharmacologic and dietary management, not surgical intervention; surgery is not indicated in this scenario.

• Prepare an insulin drip: There is no evidence of hyperglycemia, ketosis, or diabetes in this child, so initiating an insulin drip would be inappropriate and unrelated to the presenting condition.

• Lymph node size: Lymphadenopathy is not a feature of nephrotic syndrome, and changes in lymph node size would not provide useful information for monitoring this child’s condition or treatment response.

• Ketones: Ketone monitoring is relevant for patients with diabetes or fasting states but is not necessary in nephrotic syndrome, as ketonuria is not a feature of this disease.

• Bladder volume: Bladder monitoring is not required because there is no evidence of urinary obstruction or retention; fluid balance is better assessed by weight and urine output rather than bladder volume.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is ["A","C","D"]

Explanation

A. Note and report the client's food and liquid intake during meals and snacks: UAPs can monitor and document intake and output, then report to the nurse for evaluation. This is within their role.

B. Assess the client for weakness and fatigue: Assessment requires nursing judgment and interpretation of findings, which cannot be delegated to UAPs.

C. Report any client mention of pain or discomfort: UAPs may report observations or client statements to the nurse. The nurse is responsible for further assessment and management.

D. Weigh the client and report any weight gain: Daily weights and reporting results are appropriate UAP tasks, as they are routine and measurable without requiring clinical judgment.

E. Evaluate the client for sleep disturbances: Evaluation involves analysis and clinical decision-making, which must be performed by the nurse, not the UAP.

A. Advise the UAP to stop providing care so the nurse can assess the client's condition. B. Determine why the UAP did not notify the nurse of the change in the client's condition. C. Ask the UAP to position the client so the oral medications can be administered. D. Explain to the UAP that changes in a client's condition should be reported immediately.

Correct Answer is A

Explanation

A. Advise the UAP to stop providing care so the nurse can assess the client's condition: The client shows signs of acute deterioration, which may indicate a life-threatening event. Immediate assessment takes priority over continuing routine tasks or delegating care.

B. Determine why the UAP did not notify the nurse of the change in the client's condition: Investigating the UAP’s actions is important for accountability and education but is secondary to addressing the client’s urgent medical needs.

C. Ask the UAP to position the client so the oral medications can be administered: Administering medications is not the priority when the client is unstable. Ensuring patient safety and assessing the acute condition comes first.

D. Explain to the UAP that changes in a client's condition should be reported immediately: Educating the UAP is necessary to prevent future incidents but does not address the immediate need to evaluate and stabilize the deteriorating client.

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Patient Data Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is managing the care of a client with Cushing's syndrome. Which intervention(s) should the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply.

Correct Answer is ["A","C","D"]

Explanation

Correct Answer is A

Explanation

The nurse is assisting the healthcare provider with a thoracentesis for a client who has emphysema. Which equipment should the nurse have at the bedside in the event the procedure is ineffective?

The nurse is providing teaching to a client newly diagnosed with type 2 diabetes mellitus about disease management. Which response by the client indicates understanding?

An older adult male client arrives at the clinic reporting that his bladder always feels full. The client also reports a weak urine flow, frequent dribbling after voiding, and increasing nocturia with difficulty initiating the urine stream. Which action should the nurse implement?

After receiving report on an inpatient acute care unit, which client should the nurse assess first?

The nurse is caring for a client with chronic kidney disease (CKD). Which meal selection should the nurse recommend to the client?

Patient Data

Exhibits

Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.