While a child is hospitalized with acute glomerulonephritis, the parents ask why blood pressure readings are taken so often. Which response by the nurse is most accurate?

Sodium intake with meals and snacks affects the blood pressure.

Hypotension leading to sudden shock can develop at any time.

Elevated blood pressure must be anticipated and identified quickly.

Blood pressure fluctuations mean that the condition has become chronic.

Answer and Explanation

The Correct Answer is C

Choice A reason: While sodium intake can affect blood pressure, this response does not address the importance of frequent blood pressure monitoring in the context of acute glomerulonephritis.

Choice B reason: Hypotension leading to sudden shock is not a common complication of acute glomerulonephritis; instead, hypertension is more likely due to fluid retention and kidney impairment.

Choice C reason: Elevated blood pressure is a significant concern in acute glomerulonephritis due to fluid retention and decreased kidney function. Early identification and management of hypertension are crucial to prevent complications such as seizures or heart failure.

Choice D reason: Blood pressure fluctuations do not necessarily indicate that the condition has become chronic. Frequent monitoring is necessary to manage acute symptoms and prevent complications.

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Correct Answer is C

Explanation

Choice A reason: Placing an indwelling urinary catheter and instituting strict intake and output measurements can be done later if needed, but addressing the chest pain is the priority.

Choice B reason: Securing consent for coronary angiography and intervention is important but should be done after addressing the immediate chest pain and potential myocardial infarction.

Choice C reason: Administering aspirin is crucial as it acts as an antiplatelet agent, helping to reduce the risk of further clot formation and improving outcomes in the setting of acute coronary syndrome.

Choice D reason: Evaluating extremities for perfusion is important but secondary to administering aspirin in this acute situation.

A. Attempt to comfort the client by agreeing with the delusions and ask open-ended questions. B. Present a personal perception of reality in a nonconfrontational manner. C. Disagree with the statement and set clear limits on talking about it. D. Immediately inform the healthcare provider that the client is experiencing a delusional episode.

Correct Answer is B

Explanation

Choice A reason: Attempting to comfort the client by agreeing with the delusions is not therapeutic and may reinforce the delusional beliefs.

Choice B reason: Presenting a personal perception of reality in a nonconfrontational manner helps the client recognize reality without creating conflict or distress.

Choice C reason: Disagreeing with the statement and setting clear limits may be perceived as confrontational and could increase the client's distress.

Choice D reason: Informing the healthcare provider is important but should not be the immediate action. Addressing the client's delusions therapeutically is the first priority.

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While a child is hospitalized with acute glomerulonephritis, the parents ask why blood pressure readings are taken so often. Which response by the nurse is most accurate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a history of unstable angina presents to the emergency department with constant chest pressure that is unrelieved with rest. The client appears anxious, pale, and diaphoretic. After obtaining the client's vital signs, which action should the nurse take next?

Correct Answer is C

Explanation

The nurse is caring for a client who has a history of experiencing delusions. The client describes singing in a concert in the afternoon for thousands of people. Which action should the nurse take?

Correct Answer is B

Explanation

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