A nurse is performing a physical assessment for a school-age child who has acute glomerulonephritis. Which of the following findings should the nurse expect?
Decreased blood pressure
Weight loss
Elevated serum protein levels
Tea-colored urine
The Correct Answer is D
A. Decreased blood pressure: Acute glomerulonephritis typically causes fluid retention and increased vascular resistance, leading to elevated blood pressure rather than decreased blood pressure. Hypertension is a common finding due to impaired kidney function.
B. Weight loss: Clients with acute glomerulonephritis often experience fluid retention, resulting in weight gain rather than weight loss. Edema and increased extracellular fluid volume contribute to this weight gain.
C. Elevated serum protein levels: Serum protein levels are usually decreased in acute glomerulonephritis because protein is lost in the urine (proteinuria). This loss reduces the overall serum protein concentration, especially albumin.
D. Tea-colored urine: Tea-colored or cola-colored urine is a classic sign of acute glomerulonephritis. It results from hematuria caused by red blood cells leaking through the inflamed glomeruli into the urine, giving it a dark, discolored appearance.
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Related Questions
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}
Explanation
Rationale for Correct Answers:
- Level of alertness: This is a primary indicator of neurological function and potential deterioration in a child with suspected meningitis. Altered alertness may signal increased intracranial pressure or brain involvement, and it requires immediate attention.
- Mental status: While related to alertness, mental status encompasses behavior, orientation, and responsiveness. It is important to monitor next to evaluate for progression of neurological compromise after ensuring the child is responsive.
Rationale for Incorrect Choices:
- Decreased appetite: A common symptom in many illnesses but not immediately life-threatening. It is not a priority in acute neurological assessment.
- Irritability: Can be an early sign of neurological irritation but is less critical than decreased alertness and changes in mental status.
- Hypoactive bowel sounds: This may reflect reduced gastrointestinal activity from illness or immobility but is not an urgent concern compared to neurological findings.
Correct Answer is B
Explanation
A. "Fasten the harness over your infant's winter coat.": Thick clothing, like winter coats, can compress in a crash, causing the harness to fit loosely and increasing injury risk. The harness should be snug directly on the infant’s body, with blankets placed over after securing.
B. "Keep the car seat in a rear-facing position until your infant is 2 years old.": Rear-facing car seats provide the best protection for infants’ heads, necks, and spines during a crash. Infants should seat rear-facing until at least 2 years of age.
C. "Pad the backrest of the car seat with a thick blanket before securing your infant.": Adding padding behind the infant can alter the fit and safety of the car seat. It is not advised to add any padding that did not come with the seat.
D. "Ensure the airbag is activated if the car seat is in the front passenger seat.": Airbags pose a serious risk to infants in car seats placed in the front passenger seat. It is safest to place infants in the rear seat, away from active airbags.
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