A nurse is assessing a 7-year-old who has been diagnosed with acute pyelonephritis, what assessment finding requires immediate action by the nurse?

Blood pressure of 136/92 mg

Heart rate of 100 bpm

Decreased urine output

Tea-colored urine

Answer and Explanation

The Correct Answer is A

A. Hypertension (blood pressure of 136/92 mm Hg) in a child with acute pyelonephritis can indicate a severe condition that may lead to renal damage or worsening kidney function. Immediate intervention is necessary to manage high blood pressure and prevent complications.

B. A heart rate of 100 bpm is within normal limits for a 7-year-old and does not require immediate action.

C. Decreased urine output is concerning and needs monitoring, but hypertension is the more urgent issue.

D. Tea-colored urine suggests hematuria or concentrated urine, which is important but not as immediately life-threatening as high blood pressure.

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Correct Answer is C

Explanation

A. Assuming all Asians have the same culture is a generalization and may not accurately represent the specific cultural background of the family in question.

B. Hiring an interpreter may be helpful for language translation but may not provide insights into the nuances of the family's cultural beliefs and practices.

C. Directly engaging with the family and listening to their perspectives allows for a better understanding of their specific cultural beliefs and preferences.

D. While research can provide valuable information, direct communication with the family is essential for truly understanding their cultural needs and preferences.

A. Low-fat yogurt with blueberries and granola B. Cheese, banana slices, rice cakes, and whole milk C. Eggs, bacon, rye toast, and lactose-free milk D. Egg, cheese, and sausage wrapped in a flour tortilla

Correct Answer is B

Explanation

A. Granola often contains gluten, so this meal would not be suitable for someone with celiac disease.

B. Cheese, banana slices, rice cakes, and whole milk are gluten-free and appropriate for a child with celiac disease.

C. Rye toast contains gluten, which is contraindicated for someone with celiac disease.

D. Flour tortillas generally contain gluten, so this meal is not appropriate for someone with celiac disease.

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A nurse is assessing a 7-year-old who has been diagnosed with acute pyelonephritis, what assessment finding requires immediate action by the nurse?

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Naxlex Comprehensive Predictor Exams

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