A nurse is assisting in the care of a 10-year-old child.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the child is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the child's progress.

Answer and Explanation

The Correct Answer is []

Rationale for Correct Choices:

Acute glomerulonephritis: The child’s symptoms, such as dark brown urine (which indicates hematuria), recent history of streptococcal pharyngitis, swelling around the eyes, and slight weight loss — are highly suggestive of acute glomerulonephritis, a kidney condition that can follow a streptococcal infection. Elevated BUN and creatinine levels, along with proteinuria, also support this diagnosis.
Encourage child to increase fluid intake: Hydration is important in managing acute glomerulonephritis, as it helps prevent further renal damage and supports kidney function. However, fluid intake should be monitored and balanced with any renal impairment and swelling.
Restrict sodium intake: Sodium restriction is crucial in managing acute glomerulonephritis to prevent fluid retention, which can lead to worsening edema and hypertension. Given the child’s swelling and blood pressure readings, it’s important to minimize sodium intake.
Monitor urine volume and appearance every shift: Monitoring the urine volume and appearance is key in assessing kidney function and detecting worsening of the child’s condition.
Obtain daily weight: Daily weight monitoring helps detect fluid retention, which is common in acute glomerulonephritis due to edema. Significant weight changes may indicate worsening of kidney function or fluid balance.

Rationale for Incorrect Choices:

Acute asthma exacerbation: While the child has a history of asthma and is showing some wheezing and a nonproductive cough, these symptoms are not the primary concern here. The child’s dark urine, swelling, and recent history of streptococcal infection are more consistent with acute glomerulonephritis than an asthma exacerbation.
Bacterial pneumonia: Pneumonia is not indicated by the child’s symptoms. While the child has a cough and wheezing, the absence of fever, difficulty breathing, and other typical pneumonia symptoms makes this diagnosis unlikely.
Urinary tract infection: The presence of dark urine, hematuria, and proteinuria, along with a recent streptococcal infection, points more toward acute glomerulonephritis rather than a urinary tract infection.
Administer bronchodilators: While the child has wheezing, this is not the primary issue, as the main concern is the possible kidney involvement due to acute glomerulonephritis. Bronchodilators would be appropriate for asthma exacerbations but not for managing kidney issues.
Administer antipyretics: There is no indication of fever at this time, and the primary concern is the renal condition. Antipyretics would only be useful if the child developed a fever.
Administer an angiotensin-converting enzyme inhibitor : ACE inhibitors are used to treat hypertension and chronic kidney disease, but they are not typically prescribed immediately for acute glomerulonephritis without further evaluation. The child’s blood pressure is slightly elevated but not severely enough to warrant this treatment at this time.
Monitor peak expiratory flow rate daily: This parameter is useful for monitoring asthma, but it is not relevant for assessing acute glomerulonephritis. The child’s respiratory issues are less concerning than the renal symptoms in this case.
Obtain temperature every 4 hr: There is no indication that the child has a fever, and thus, temperature monitoring is not as critical as monitoring renal function through urine appearance, volume, and daily weight.
Monitor oxygen saturation levels every 4 hr: While the child has some respiratory symptoms, the primary issue is related to kidney function. Oxygen saturation monitoring is more appropriate for managing respiratory conditions, not for assessing the severity of acute glomerulonephritis.

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Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"B"}

Explanation

Rationale for Correct Choices:

Seizures: The adolescent’s fever, headache, photophobia, and neck stiffness (resistance to flexion) are consistent with signs of meningitis, which can lead to seizures, especially in the setting of increased intracranial pressure. Seizures are a known complication of untreated or severe meningitis.
Signs of meningeal irritation: The adolescent demonstrates classic signs of meningeal irritation, such as photophobia, severe headache, and neck stiffness, which suggest inflammation of the meninges. This is a key indicator of potential meningitis and the associated risk of seizures.

Rationale for Incorrect Choices:

Lyme disease: While Lyme disease can cause neurological symptoms, including headache and fever, the absence of a characteristic erythema migrans rash or recent tick exposure makes it less likely.
Constipation: Constipation is not a likely complication given the adolescent's current symptoms, which are focused on fever, headache, and neurological signs. It does not explain the risk for seizures.
Mononucleosis: Although mononucleosis can cause fever and malaise, it typically does not present with neck stiffness, photophobia, or the acute onset of severe headache that is suggestive of meningitis. The symptoms in this case are more concerning for meningitis.
Pneumonia: Pneumonia is unlikely given the absence of respiratory findings such as cough or difficulty breathing. The symptoms are more consistent with a central nervous system infection, like meningitis, than a respiratory infection.
Fever: While fever is present in meningitis, it alone does not indicate the risk for seizures. It is the combination of fever, headache, photophobia, and meningeal signs that increases the risk for complications like seizures.
Inability to eat and drink: The inability to eat and drink is likely a result of nausea and vomiting, which is common in many illnesses, including meningitis. However, it is not a direct indicator of the risk for seizures, which is more strongly linked to meningeal irritation.
Respiratory findings: There are no significant respiratory symptoms, such as difficulty breathing or abnormal lung sounds, making respiratory findings irrelevant in this case. The adolescent’s symptoms are primarily neurological.

A. "It measures the amount of oxygen circulating in the blood." B. "It measures the amount of immature white blood cells." C. "It measures the glucose circulating in the blood stream. D. "It measures the amount of red blood cells."

Correct Answer is C

Explanation

A. "It measures the amount of oxygen circulating in the blood." The HbA1c test does not measure oxygen levels. Oxygen levels in the blood are measured through tests like pulse oximetry or arterial blood gas tests.
B. "It measures the amount of immature white blood cells." The HbA1c test measures the average blood glucose levels over the past 2-3 months, not white blood cells. The immature white blood cell count is assessed through a different blood test (e.g., a complete blood count).
C. "It measures the glucose circulating in the blood stream." The HbA1c test reflects the average blood glucose levels over the past 2-3 months by measuring the percentage of hemoglobin that has glucose attached to it.
D. "It measures the amount of red blood cells." The HbA1c test does not measure the number of red blood cells; it measures the percentage of hemoglobin in red blood cells that is bound to glucose, which helps assess blood sugar control over time.

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Naxlex Comprehensive Predictor Exams

Exhibits Drag 1 condition and 1 client finding to fill in each blank in the following sentence. The client is at risk for developing dropdownas evidenced bydropdown.

Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"B"}

Explanation

A nurse is reinforcing teaching with an adolescent client about the purpose of the glycosylated hemoglobin (HbA1c) test. Which of the following descriptions should the nurse include in the teaching?

Correct Answer is C

Explanation

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