A nurse is caring for a school-age child in the pediatric unit.

Exhibits

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

Answer and Explanation

The Correct Answer is []

Nephrotic Syndrome: The child presents with periorbital and abdominal edema, foamy dark-colored urine, significant proteinuria (24 mg/dL), hypoalbuminemia (1.4 g/dL), and hyperlipidemia (cholesterol 465 mg/dL), all of which are classic indicators of nephrotic syndrome. The elevated ESR and low sodium further support an inflammatory renal process with fluid retention.
Chronic Kidney Disease: CKD is a long-term progressive decline in kidney function. This child shows acute findings with severe proteinuria and low albumin, consistent with nephrotic syndrome, not CKD.
Acute Glomerulonephritis: Usually presents with hematuria (cola-colored urine), hypertension, and mild proteinuria. This client has severe proteinuria, hypoalbuminemia, and edema, which are more typical of nephrotic syndrome.
Hemolytic Uremic Syndrome: Commonly follows a gastrointestinal illness and includes anemia, thrombocytopenia, and acute kidney injury. This child’s platelets are elevated, not low, and there's no history of diarrheal illness, making HUS unlikely.
Encourage a low sodium diet: Sodium restriction helps manage fluid retention and edema which are key concerns in nephrotic syndrome. It also prevents worsening of ascites and periorbital swelling.
Administer oral corticosteroids: This is the first-line treatment for idiopathic nephrotic syndrome, especially in children. Corticosteroids reduce glomerular permeability, limiting protein loss in the urine and promoting remission.
Initiate peritoneal dialysis: Dialysis is only indicated in severe renal failure, which this child does not have. There’s no indication of uremia or electrolyte crisis, so dialysis is not appropriate at this stage.

Intake and output: Essential for assessing fluid balance. Children with nephrotic syndrome may retain fluid or have decreased urine output, making I&O a crucial measure.
Daily weight: This is the most accurate way to track fluid retention or loss. Daily weight is important for evaluating response to treatment, especially as edema resolves.

Head circumference: This is monitored in infants and toddlers, especially to assess for hydrocephalus or growth delays. It is not relevant for a school-age child with kidney issues.

HbA1C: A measure of long-term blood glucose control, used for diagnosing and managing diabetes. Has no relevance in the diagnosis or management of nephrotic syndrome.
Urine specific gravity: While useful in initial diagnosis (and already elevated), it is not the best indicator of ongoing progress. Daily weight and I&O are more practical and reliable for assessing edema and treatment response.

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Correct Answer is D

Explanation

A. Discuss the client's preferences for determining a repositioning schedule. While it's important to consider the client's comfort, repositioning must follow clinical guidelines (typically every 2 hours) to prevent pressure injuries, especially in clients with limited mobility post-stroke.
B. Raise the side rails on both sides of the client's bed during repositioning. Raising both side rails can be considered a form of restraint if not medically justified. Only one rail should be raised for safety and support unless otherwise indicated by facility policy.
C. Reposition the client without the use of assistive devices. Repositioning a client post-stroke without proper equipment increases the risk of injury to both the client and the nurse. Assistive devices promote safety and proper body mechanics.
D. Evaluate the client's ability to help with repositioning. This is the first and most important step. Assessing the client’s physical capability and level of consciousness ensures that the nurse uses the appropriate technique and equipment for safe repositioning.

A. Fill out an incident report. B. Report the incident to the nurse manager. C. Notify the provider. D. Measure the client's vital signs.

Correct Answer is D

Explanation

A. Fill out an incident report. While completing an incident report is necessary for documentation and quality improvement, it is not the priority action. The nurse must first assess the client's condition to address any immediate risks.
B. Report the incident to the nurse manager. Informing the nurse manager is important for accountability and follow-up, but client safety and assessment come first before escalating the issue to management.
C. Notify the provider. The provider should be informed after the nurse has assessed the client and gathered relevant data such as vital signs. This allows the provider to make informed decisions about further treatment or monitoring.
D. Measure the client's vital signs. Assessing the client is the first priority following a medication error to identify any adverse effects. Vital signs provide immediate data on the client’s physiological status and guide urgent interventions if needed.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to reposition a client who had a stroke. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse realizes that the wrong medication has been administered to a client. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

A nurse is receiving a telephone prescription from a provider for a client who requires additional medication for pain control. Which of the following entries should the nurse make in the medical record?

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