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 {"dropdown-group-1":"B","dropdown-group-2":"A"}
Explanation
Disseminated Intravascular Coagulation (DIC)- Bacterial meningitis can lead to septicemia, which may trigger DIC. Petechiae or purpura (noted earlier) suggest potential coagulation abnormalities. DIC results in widespread clotting and subsequent bleeding, which can be life-threatening.
Hydrocephalus- Meningeal inflammation can obstruct cerebrospinal fluid (CSF) flow, leading to increased intracranial pressure (ICP). Symptoms such as headache, lethargy, irritability, and nuchal rigidity suggest increased ICP and potential hydrocephalus development.
Hypothermia- The child presents with fever (38.7°C/101.7°F), which is typical in bacterial infections rather than hypothermia. Septic shock can cause hypothermia in late stages, but early-stage bacterial meningitis more commonly causes fever.
Correct Answer is C
Explanation
A. Lymphadenopathy. While some viral infections cause lymph node swelling, lymphadenopathy is not a hallmark sign of rubeola (measles).
B. Steatorrhea. Steatorrhea (fatty stools) is associated with conditions like cystic fibrosis and celiac disease, not rubeola.
C. Koplik spots. Koplik spots are small, white lesions with a red base found on the buccal mucosa, and they are a classic early sign of measles (rubeola).
D. Paroxysmal coughing. Paroxysmal coughing is characteristic of pertussis (whooping cough), not rubeola.
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