A nurse is assisting in the planning of care for a client who has acute glomerulonephritis. Which of the following interventions should the nurse recommend including in the plan of care?

Place the client on a low-sodium diet.

Encourage increased fluid intake.

Obtain weekly weight.

Encourage frequent ambulation.

Answer and Explanation

The Correct Answer is A

Choice A reason: A low-sodium diet is essential for clients with acute glomerulonephritis to prevent fluid retention and reduce the workload on the kidneys. This dietary modification helps manage edema and hypertension, common complications of the condition. By limiting sodium intake, the body retains less water, which helps control swelling and blood pressure, making it a crucial intervention in the plan of care.

Choice B reason: Encouraging increased fluid intake is not recommended for clients with acute glomerulonephritis. Excessive fluid intake can lead to fluid overload, worsening edema and hypertension. The kidneys are already compromised in their ability to excrete fluid efficiently, so increasing fluid intake would exacerbate these issues. Instead, fluid intake should be carefully monitored and potentially restricted to prevent further strain on the kidneys.

Choice C reason: Obtaining weekly weight is not specific enough to monitor the acute phase of glomerulonephritis. Daily weights are more appropriate to closely monitor fluid balance and detect changes in edema. Daily weight measurements can help in assessing the effectiveness of interventions such as a low-sodium diet or diuretics and provide timely information for adjusting the plan of care.

Choice D reason: Encouraging frequent ambulation, while generally beneficial for overall health, is not a specific intervention for managing acute glomerulonephritis. The primary focus should be on dietary modifications and monitoring fluid balance to manage symptoms and prevent complications. Ambulation should be encouraged based on the client's overall condition and ability but is not a direct intervention for glomerulonephritis.

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Correct Answer is ["C","E"]

Explanation

Choice A reason: Massaging erythematous bony prominences can actually cause further damage to the skin and underlying tissues. It is better to relieve pressure and monitor the skin closely for any signs of breakdown.

Choice B reason: Implementing a turning schedule every 4 hours is not frequent enough. Clients with spinal cord injuries should be repositioned every 2 hours to prevent prolonged pressure on any one area and reduce the risk of skin breakdown.

Choice C reason: The correct answer is c because using pillows to keep the heels off the bed surface helps prevent pressure ulcers on the heels, which are common sites of skin breakdown in immobilized clients. This technique helps distribute pressure more evenly and reduces the risk of ulcers.

Choice D reason: Keeping environmental humidity less than 30% is not recommended, as low humidity can lead to dry and cracked skin, increasing the risk of skin breakdown. Maintaining a moderate humidity level helps keep the skin hydrated and intact.

Choice E reason: The correct answer is e because minimizing skin exposure to moisture, such as sweat, urine, or wound exudate, helps prevent maceration and skin breakdown. Using moisture-wicking materials and keeping the skin dry and clean are important measures in skin care for paralyzed clients.

A. Osteoarthritis B. Lung cancer C. Liver cirrhosis D. Dyspepsia E. Seizures

Correct Answer is ["B","C","E"]

Explanation

Choice A reason: Osteoarthritis is a degenerative joint disease and is not associated with SIADH. It does not typically affect the body's regulation of antidiuretic hormone (ADH) or fluid balance.

Choice B reason: Lung cancer, particularly small cell lung cancer, is a common cause of SIADH. Tumor cells can produce and secrete ADH, leading to inappropriate water retention and hyponatremia. Therefore, asking about lung cancer history is important in the assessment.

Choice C reason: The correct answer is c because liver cirrhosis can lead to secondary conditions that may affect fluid balance and ADH secretion. Although not a direct cause of SIADH, liver dysfunction can complicate the clinical picture and contribute to fluid retention issues.

Choice D reason: Dyspepsia, or indigestion, is not related to SIADH and does not typically impact ADH regulation. It is a gastrointestinal issue that does not affect fluid balance.

Choice E reason: The correct answer is e because seizures can be associated with conditions that trigger SIADH. Neurological disorders, including brain injuries and infections, can lead to the inappropriate release of ADH, resulting in fluid retention and hyponatremia.

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A nurse is assisting in the planning of care for a client who has acute glomerulonephritis. Which of the following interventions should the nurse recommend including in the plan of care?

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Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who has a spinal cord injury and paralysis. Which of the following actions should the nurse include in the plan to decrease the client’s risk of skin breakdown? (Select all that apply.)

Correct Answer is ["C","E"]

Explanation

A nurse is collecting data from a client. The provider suspects the client may have the syndrome of inappropriate antidiuretic hormone (SIADH). When obtaining a medical history, the nurse should ask for additional information about which of the following conditions? (Select all that apply.)

Correct Answer is ["B","C","E"]

Explanation

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