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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Correct Answer is ["A","E","F"]

Explanation

Rationale for Correct Choices:

The client reports he was able to sleep through the night: Adequate rest indicates improved comfort and effective pain management postoperatively.
The left arm is warm to touch: Warmth confirms adequate circulation and tissue perfusion following surgery.
The client's left shoulder and collarbone are symmetric: Symmetry suggests proper surgical alignment and absence of acute displacement or swelling.

Rationale for Incorrect Choices:

Continued numbness in the left arm, tingling, and inability to move fingers: These findings raise concern for possible neurovascular compromise or prolonged effects of the nerve block.
Mild nausea and lack of desire to eat breakfast: This can be a transient side effect of anesthesia or analgesics but requires monitoring for persistence.
A 3 cm × 5 cm area of blood noted on the bandage: Postoperative dressings should have minimal drainage, so this amount of blood warrants assessment for active bleeding or hematoma formation.

A. Advise the client to grab hold of the gait belt for added support. B. Support the client in an upright position until the belt is removed. C. Use the gait belt to slowly guide the client back to the room. D. Ease the client to the floor while holding the gait belt securely.

Correct Answer is D

Explanation

A. Advise the client to grab hold of the gait belt for added support: Once a client begins to fall, instructing them to hold the belt is ineffective and unsafe. Immediate action is needed to prevent injury.

B. Support the client in an upright position until the belt is removed: Attempting to maintain the client upright during a fall increases the risk of both the client and nurse sustaining injury.

C. Use the gait belt to slowly guide the client back to the room: Trying to walk a falling client back to the room is unsafe and does not prevent injury.

D. Ease the client to the floor while holding the gait belt securely: Safely lowering the client to the floor while maintaining control of the gait belt minimizes the risk of injury to both the client and the nurse, following proper fall safety procedures.

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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

Correct Answer is ["A","E","F"]

Explanation

After applying a gait belt, the nurse assists a client with ambulation. While in the hallway, the client begins to fall. Which action should the nurse implement?

Correct Answer is D

Explanation

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Patient Data Exhibits Choose the most likely options for the information missing from the statements by selecting from the lists of options provided. Based on the client's condition, the priority need will be to address dropdown. In addition, he will need interventions to prevent dropdown_.

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.