What is the priority action the nurse will take for a 4-year old client admitted with minimal change nephrotic syndrome (MCNS) who has hypertension and facial edema?
Monitor the client's fluid volume and hydration status.
Teaching the client's parents about and preparing for a renal biopsy.
Consulting with a registered dietician about adequate intake.
Use only sterile techniques to prevent infections.
The Correct Answer is A
In a client with minimal change nephrotic syndrome (MCNS), the primary concern is the management of fluid volume and hydration status. MCNS is characterized by increased glomerular permeability, leading to excessive protein loss in the urine and subsequent hypoalbuminemia. This can result in fluid retention and edema formation, including facial edema.
Hypertension is a common complication in clients with MCNS, and it further contributes to fluid retention and potential complications. Therefore, closely monitoring the client's fluid volume and hydration status, including daily weights, intake and output measurements, and assessment of edema, is crucial to detect any changes and guide appropriate interventions.
While other actions, such as consulting with a registered dietitian about adequate intake or using sterile technique to prevent infections, may be important aspects of the client's care, they are not the priority in this situation. The immediate concern is managing the client's hypertension and fluid volume status to prevent complications associated with MCNS.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Hemoglobin A1C is a blood test that provides an average blood glucose level over the past 2-3 months. Regular monitoring of A1C levels helps to assess the effectiveness of lifestyle modifications and treatment plans and guides adjustments in management if necessary.
Daily exercise is another essential aspect of managing pre-diabetes. Regular physical activity helps improve insulin sensitivity, promotes weight management, and reduces the risk of developing type 2 diabetes. The nurse should educate patients on the importance of incorporating physical activity into their daily routine and provide recommendations on suitable exercise types and durations.
While other options may be relevant for patients with diabetes, they are not specifically tailored to pre-diabetes, which is a condition where blood glucose levels are higher than normal but not yet meeting the criteria for diabetes.
Hypoglycemia and injection site infection are more relevant concerns for individuals with diabetes who require insulin or other medications to manage their blood sugar levels. Increasing carbohydrate intake and administering insulin are not appropriate recommendations for pre-diabetes management, as they can contribute to elevated blood glucose levels.
Correct Answer is B
Explanation
Opioid tolerance occurs when the body becomes less responsive to the effects of opioids over time. This means that higher doses of the medication are needed to achieve the same level of pain relief that was previously achieved with lower doses. Opioid tolerance is a common phenomenon in long-term opioid therapy and can occur in patients who have been using opioids for an extended period.
Opioid abstinence syndrome, also known as opioid withdrawal, refers to the set of symptoms that occur when a person abruptly stops or reduces their use of opioids after developing physical dependence.
Opioid toxicity refers to the harmful effects that occur when an individual takes an excessive dose of opioids, leading to potentially life-threatening complications. It is characterized by symptoms such as respiratory depression, sedation, pinpoint pupils, and decreased level of consciousness.
Opioid addiction is a complex condition characterized by compulsive drug-seeking behavior, loss of control over opioid use, and continued use despite negative consequences.
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