A nurse is planning care for a school-age child who has acute glomerulonephritis. Which of the following interventions should the nurse include?
Monitor blood pressure every 4 hr.
Increase fluid consumption.
Implement a protein-restricted diet.
Collect and strain all urine for sediment.
The Correct Answer is A
A. "Monitor blood pressure every 4 hr." Acute glomerulonephritis can cause hypertension due to fluid retention and impaired kidney function. Regular monitoring is essential to detect and manage hypertension early.
B. "Increase fluid consumption." Fluid intake is often restricted to prevent fluid overload, especially if there is hypertension, edema, or decreased urine output.
C. "Implement a protein-restricted diet." A protein-restricted diet is not necessary unless the child has severe renal impairment. In most cases, moderate protein intake is recommended.
D. "Collect and strain all urine for sediment." While hematuria (blood in urine) is common in acute glomerulonephritis, straining urine for sediment is not a standard intervention for this condition.
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Related Questions
Correct Answer is B
Explanation
A. Elevated temperature. An elevated temperature is a common symptom of infection, including bacterial pneumonia, but it is not a direct risk factor for aspiration. The concern for aspiration is more related to a child's ability to protect their airway.
B. Neurological deficit. A neurological deficit, such as a decreased level of consciousness or impaired swallowing reflexes, increases the risk of aspiration. A child with neurological impairment may have difficulty swallowing or protecting their airway, making them more prone to inhaling food, fluids, or other substances into the lungs, leading to aspiration pneumonia.
C. Inspiratory wheezing. Inspiratory wheezing is more likely to be associated with conditions like asthma or airway obstruction, not specifically with aspiration. It does not directly indicate a risk for aspiration.
D. Rapid respirations. Rapid respirations can be a sign of respiratory distress, common in pneumonia, but they do not directly indicate a risk for aspiration. The risk for aspiration is more closely linked to issues with swallowing and airway protection, not just the rate of respiration.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Explanation
Severe Pain Management: The child's pain increased from 7/10 to 10/10, indicating worsening vaso-occlusive crisis. IV hydromorphone (Dilaudid) is a strong opioid analgesic commonly used for severe sickle cell pain when first-line options (e.g., morphine) are insufficient. Swelling and warmth in the right knee suggest ongoing vaso-occlusion and inflammation. Increased blood pressure (120/74 mm Hg) and respiratory rate (25/min) likely indicate pain-related distress.
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