A 9-year-old child who weighs 30 kg has assessment findings of 200 mL of urine in 24 hours, creatinine 4.0 mg/dL, and blood urea nitrogen of 23 mg/dL. What is the priority nursing intervention?

Numbness and tingling feeling in her legs.

Fever of 100.4°F (38°C).

Pain at the incision site.

Sleeping with occasional snoring.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Collaborating with the team to begin peritoneal dialysis is the priority nursing intervention for a 9-year-old child with assessment findings of low urine output, high creatinine, and elevated blood urea nitrogen. These indicators suggest acute kidney injury, and initiating peritoneal dialysis is crucial to remove waste products and excess fluids.

Choice B rationale:

Strictly monitoring intake and output is important, but the child's current lab values and condition indicate the need for more immediate intervention through dialysis.

Choice C rationale:

Ensuring a low-sodium, low-phosphorus, and low-protein diet is important for renal health, but it's not the priority over addressing the acute kidney injury.

Choice D rationale:

Monitoring blood pressure is relevant but does not address the acute kidney injury that requires immediate attention. Assessment Findings for Adolescent Client:

Choice A rationale:

Numbness and tingling feeling in her legs require immediate action. These symptoms could indicate nerve compression or compromised blood flow due to the rod placement and need prompt assessment to prevent complications.

Choice B rationale:

A fever of 100.4°F (38°C) after surgery is common and can be managed with appropriate interventions, but it's not the most urgent concern in this case.

Choice C rationale:

Pain at the incision site is expected after surgery and should be managed appropriately, but it's not an immediate priority over potential neurovascular issues.

Choice D rationale:

Sleeping with occasional snoring might be related to anesthesia or positioning but doesn't require immediate action compared to the potential complications indicated by numbness and tingling.

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Correct Answer is B

Explanation

Choice A rationale:

Neck vein distention might be seen in conditions affecting venous return to the heart, such as heart failure, but it's not a specific symptom of closed head injury.

Choice B rationale:

Fixed, dilated pupils are a classic sign of increased intracranial pressure. The pressure can compress the cranial nerves, leading to changes in pupillary size and reactivity.

Choice C rationale:

Shortness of breath is more related to respiratory issues and might not be directly linked to a closed head injury.

Choice D rationale:

Glycosuria, the presence of glucose in the urine, is not a primary symptom of closed head injury. It could be related to diabetes or other metabolic conditions.

A. "My child will no longer be affected by this condition once we start physical therapy.”. B. "It will be optimal to have a multidisciplinary approach for the best outcomes.”. C. "There are multiple options for treatment including medications, surgeries, and braces.”. D. "I should expect socialization with children who do not have cerebral palsy in school.".

Correct Answer is A

Explanation

"My child will no longer be affected by this condition once we start physical therapy.”.

Choice A rationale:

Cerebral palsy is a lifelong condition that affects muscle control and movement. Physical therapy can improve functionality, but it cannot completely cure or eliminate the condition. This statement demonstrates a misunderstanding of the nature of cerebral palsy.

Choice B rationale:

Choice B is accurate. Cerebral palsy management often involves a multidisciplinary approach including physical therapy, occupational therapy, and other interventions to achieve the best outcomes.

Choice C rationale:

Choice C is correct. There are indeed various treatment options for cerebral palsy, including medications, surgeries, and braces, depending on the severity and specific needs of the individual.

Choice D rationale:

The statement in Choice D is accurate. Inclusion and socialization with typically developing peers is encouraged, and schools often promote interactions among children with and without disabilities.

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A 9-year-old child who weighs 30 kg has assessment findings of 200 mL of urine in 24 hours, creatinine 4.0 mg/dL, and blood urea nitrogen of 23 mg/dL. What is the priority nursing intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 15-year-old patient with a closed head injury is admitted to the pediatric intensive care unit and is intubated. The nurse should monitor the patient for which symptom?

Correct Answer is B

Explanation

Which statement, if made by a caregiver of a 2-year-old child diagnosed with cerebral palsy requires further discussion?

Correct Answer is A

Explanation

A child is admitted to the hospital with a vaso-occlusive sickle cell crisis. Which prescription by the health care provider should the nurse implement first?

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