A nurse is caring for a child who has acute glomerulonephritis. Which of the following actions is the nurse's priority?
Maintain a saline-lock.
Check the child's day weight
Place the child on a no-salt-added diet.
Educate the parents about potential complications
The Correct Answer is B
A. Maintain a saline-lock:
Maintaining a saline lock is important for potential intravenous access, but it is not the most urgent priority compared to actions that directly monitor the child's condition and help manage the disease.
B. Check the child's daily weight:
Monitoring daily weight is crucial in acute glomerulonephritis, as it helps assess fluid balance and detect early signs of fluid retention or worsening kidney function, which are key concerns in this condition. This makes it a priority action.
C. Place the child on a no-salt-added diet:
While dietary modifications can be important for managing various health conditions, including kidney issues, this is not the top priority in this situation. Reducing salt intake can help manage fluid retention, but it is not the nurse's priority action at this moment.
D. Educate the parents about potential complications:
Patient education is crucial, especially in chronic conditions, but in this acute care scenario, the nurse's immediate priority is to address the child's needs. Educating parents about potential complications should be done, but it's not the most immediate action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Elevate the head of the bed 15 to 30 degrees with head maintained a midline position.
Correct Explanation: This intervention is appropriate for a child with an acute head injury.
Explanation: Elevating the head of the bed helps reduce intracranial pressure by facilitating venous drainage from the head. However, it's important to keep the head in a midline position to prevent neck flexion, which can obstruct venous flow. Elevating the head 15 to 30 degrees is a standard approach for managing intracranial pressure in patients with head injuries.
B. Maintain an active stimulating environment.
Incorrect Explanation: Maintaining an active stimulating environment is not suitable for a child with an acute head injury.
Explanation: A child with an acute head injury should be in a quiet and calm environment. Overstimulation can worsen the condition by increasing intracranial pressure. It's important to minimize stimuli to allow the brain to heal.
C. Perform active chest percussion and suctioning every 1 to 2 hours.
Incorrect Explanation: Chest percussion and suctioning are not relevant interventions for an acute head injury.
Explanation: Active chest percussion and suctioning are typically used to manage respiratory conditions. While maintaining good respiratory function is important for overall patient care, it's not a primary intervention for an unconscious child with a head injury.
D. Instruct child on performing active range of motion.
Incorrect Explanation: Instructing the child on performing active range of motion is not appropriate for an unconscious child with a head injury.
Explanation: An unconscious child cannot actively perform range of motion exercises. Additionally, it's not a priority intervention in the acute phase of head injury management.
Correct Answer is A
Explanation
A) A step-wise approach will be used to reduce the dosage gradually.
Explanation:
After a certain period of seizure control, a healthcare provider may consider gradually tapering and discontinuing anti-seizure medications in consultation with the child's neurologist. This is often done in a step-wise manner to monitor the child's condition and minimize the risk of seizure recurrence. Stopping anti-seizure medications abruptly can increase the risk of seizures returning. Therefore, the response provided in option A is the most accurate and relevant to the situation.
The other options are incorrect:
B) Your child will always suffer seizures:
This statement is not accurate, as some children with epilepsy can achieve long-term seizure control with appropriate treatment. Epilepsy management varies from person to person, and many individuals can experience extended periods of seizure freedom.
C) This is always a hereditary disorder:
Epilepsy can have both genetic and non-genetic causes. While there are genetic forms of epilepsy, not all cases are hereditary. Epilepsy can be caused by a variety of factors, including brain injuries, infections, and other medical conditions.
D) Only her male offspring will experience seizures:
Epilepsy does not discriminate based on gender. Both males and females can be affected by epilepsy. This statement is not accurate and does not reflect the reality of epilepsy as a medical condition.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.