A nurse is assessing a child who has acute kidney injury. Which of the following clinical manifestations should the nurse expect?

A. Obtain a daily weight:

This is an appropriate action. Monitoring daily weights can help assess fluid balance and detect fluid retention, which is common in children with kidney disorders like acute glomerulonephritis. Sudden weight gain or fluid overload may indicate worsening kidney function and the need for intervention.

B. Strain the urine:

Straining the urine may be indicated to monitor for the presence of blood or protein, which are common findings in acute glomerulonephritis. Straining the urine is not necessary, as hematuria is a common finding and does not indicate kidney damage.

C. Monitor blood glucose level every 4 hr:

Monitoring blood glucose levels every 4 hours is not directly related to the care of a child with acute glomerulonephritis. Blood glucose monitoring is more relevant in conditions such as diabetes mellitus. However, monitoring electrolyte levels, including blood glucose, may be part of routine laboratory testing in children with kidney disorders.

D. Recommend strict bed rest:

Strict bed rest is not typically recommended for children with acute glomerulonephritis unless there are specific complications or severe symptoms requiring immobilization. While some activity restriction may be recommended during the acute phase of the illness, strict bed rest may lead to complications such as deconditioning and venous thromboembolism.

A. FACES: The FACES pain scale is a visual analog scale commonly used with older children who can point to or select a facial expression that best represents their pain level. It may not be suitable for infants who may not have the cognitive or motor skills to use the scale effectively.

B. COMFORT: The COMFORT scale assesses pain in infants and young children based on behaviors such as crying, facial expressions, and body movements. It evaluates parameters such as alertness, calmness, respiratory response, physical movement, and muscle tone. The COMFORT scale is suitable for assessing pain in infants and young children, including those who are postoperative.

C. CRIES: The CRIES scale is a neonatal pain assessment tool that evaluates crying, oxygen saturation, vital signs, expression, and sleeplessness. While it is designed for newborns and infants up to 6 months of age, it may not be as appropriate for a 12-month-old infant who is postoperative and beyond the neonatal period.

D. FLACC: The FLACC scale assesses pain in infants and young children based on five behavioral categories: facial expression, leg movement, activity level, cry, and consolability. It is commonly used in pediatric settings and is suitable for assessing pain in infants who are postoperative.