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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Place a pillow under the child's head.

Explanation: While providing comfort is important, the priority in this scenario is to ensure the child's safety. Placing a pillow under the head can be considered after addressing immediate safety concerns.

B. Clear the area of hazards.

Explanation: Correct Choice. Ensuring the area is clear of hazards is the nurse's priority. During a seizure, the child can experience uncontrolled movements, and having hazards around can lead to injuries. Clearing the area helps prevent harm. But priority is to position the child side lying.

C. Position the child side-lying.

Explanation: Correct Choice. Placing the child in a side-lying position helps prevent choking and aspiration due to vomiting during the seizure. It also minimizes the risk of airway obstruction and helps manage secretions.

D. Loosen restrictive clothing.

Explanation: While loosening restrictive clothing can facilitate breathing, the priority in this situation is addressing safety concerns related to the seizure and vomiting. Ensuring a clear and safe environment takes precedence.

A. Symptomatic of decorticate posturing B. Symptomatic of decerebrate posturing C. Indicators of severe brain damage D. Normal Findings

Correct Answer is D

Explanation

Reflexes play a crucial role in evaluating the neurological status of infants.

Moro reflex: Also known as the startle reflex, the Moro reflex is a normal response in infants. It occurs when an infant is startled by a sudden noise or movement. The baby responds by extending their arms and legs, followed by a quick contraction. This reflex usually disappears around 4-6 months of age.

Tonic neck reflex (fencer's reflex): This reflex involves turning an infant's head to one side, causing the arm on that side to extend and the opposite arm to flex. It's a normal reflex that typically disappears around 4-6 months of age.

Withdrawal reflex: The withdrawal reflex is a normal response to a stimulus, such as touching a baby's foot with a cold object. The baby will pull their leg away in response to the stimulus.

Symptomatic of decorticate or decerebrate posturing (options A and B):

Decorticate and decerebrate posturing are abnormal postures seen in individuals with severe brain damage or injury. Decorticate posturing involves the arms being flexed and held close to the body, while decerebrate posturing involves the arms being extended and the wrists being pronated. These reflexes are typically indicative of significant neurological dysfunction and are not expected in a 2-month-old infant after a car accident.

Indicators of severe brain damage (option C):

The reflexes described (Moro, tonic neck, and withdrawal reflexes) are not indicative of severe brain damage in a 2-month-old infant. These reflexes are normal for an infant of this age and are part of their typical neurological development.

Normal findings (option D):

The reflexes described are normal findings in a 2-month-old infant and are expected as part of their developmental milestones.

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A nurse is caring for a child who has acute glomerulonephritis. Which of the following actions is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a child who is having a tonic-clonic seizure and vomiting. Which of the following actions is the nurse's priority?

Correct Answer is C

Explanation

The nurse is doing a neurologic assessment on a 2-month-old infant after a car accident. Moro, tonic neck, and withdrawal reflexes are present. The nurse should recognize that these reflexes are:

Correct Answer is D

Explanation

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