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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

School-age children typically have a growing awareness of their bodies and an understanding of potential harm or pain. They may fear procedures or treatments that involve physical discomfort, such as injections, blood draws, or invasive procedures. The fear of experiencing pain or bodily injury can cause anxiety and distress in school-age children.

It is important for the nurse to acknowledge and address the child's fear of pain or bodily injury by providing age-appropriate explanations, offering reassurance, and implementing strategies to minimize discomfort. This may involve using distraction techniques, providing emotional support, and ensuring proper pain management during procedures.

While loss of privacy and control, separation anxiety, and stranger anxiety can also be stressors for school-age children, the fear of pain or bodily injury is often a significant concern that may require specific attention and interventions from the nurse.

A. Metoprolol 50 mg. PO daily. B. Maintain accurate intake and output records. C. Furosemide (Lasix) 40 mg IV push. D. Encourage fluid intake more than 2000 mL/day

Correct Answer is C

Explanation

The client's symptoms of bounding peripheral pulses, weight gain, pitting edema, and moist crackles bilaterally suggest fluid volume overload or fluid retention. Furosemide (Lasix) is a loop diuretic that helps to promote diuresis and reduce fluid volume. Administering the medication promptly can help address the client's symptoms and alleviate the fluid overload.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

As a nurse caring for a school-age child, the nurse may anticipate which primary stressor/fear?

Correct Answer is C

Explanation

The health care provider has written the following orders for a client with bounding peripheral pulses, weight gain of 2 lb., pitting edema, and moist crackles bilaterally. Which order will the nurse complete first?

Correct Answer is C

Explanation

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