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.

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Free Nursing Study Resources

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

Explanation

A. Explain the purpose of a low bacteria diet: A low bacteria (neutropenic) diet is indicated for immunocompromised clients, not for MRSA wound infections. It does not reduce transmission or address wound healing.

B. Use standard precautions and wear a mask: Standard precautions are necessary, but a mask is not required for MRSA unless there is risk of aerosolization (e.g., respiratory infection). The key precaution is contact isolation, not routine mask use.

C. Monitor the client’s white blood cell count (WBC): Tracking WBC trends helps identify worsening infection or systemic involvement such as sepsis. This is an important part of managing MRSA.

D. Institute contact precautions for staff and visitors: MRSA is transmitted by direct contact with infected drainage or contaminated surfaces, so gown and glove use with contact precautions are essential.

E. Send wound drainage for culture and sensitivity: Culturing identifies the causative organism and determines antibiotic sensitivity, which guides effective treatment planning.

A. Assess for spinal scoliosis. B. Compare shoulder symmetry. C. Observe gait while walking. D. Palpate for joint nodules.

Correct Answer is C

Explanation

A. Assess for spinal scoliosis: While scoliosis can affect posture and mobility, it is less likely to immediately impact the client’s safety in performing daily activities at home.

B. Compare shoulder symmetry: Shoulder asymmetry may indicate musculoskeletal issues but is not the most critical factor in evaluating fall risk or functional independence.

C. Observe gait while walking: Gait assessment provides direct information about balance, coordination, and mobility, which are key indicators of fall risk and home safety. Observing how the client walks helps the nurse plan interventions to prevent injury.

D. Palpate for joint nodules: Detecting nodules can identify conditions such as osteoarthritis, but the presence of nodules alone does not provide immediate insight into functional mobility or home safety.

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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

A client with foul smelling drainage from an incision on the upper left arm is admitted with a suspected methicillin-resistant Staphylococcus aureus (MRSA). Which nursing intervention(s) should the nurse include in the plan of care (POC)? Select all that apply.

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

Explanation

The nurse is performing a functional assessment of an older adult to determine safety in the home. Which musculoskeletal assessment is most important for the nurse to include?

Correct Answer is C

Explanation

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The nurse applies a blood pressure cuff around a client's left thigh. To measure the client's blood pressure, where should the diaphragm of the stethoscope be placed? (Mark the location on one of the images.)

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.