A nurse is providing home care instructions to the parents of a child who is in the edema phase of nephrotic syndrome. Which of the following instructions should the nurse include in the teaching?

Restrict the child's potassium intake.

Provide quiet activities for the child.

Weigh the child once a week.

Administer acetaminophen to the child daily.

Answer and Explanation

The Correct Answer is B

A. Restrict the child's potassium intake. Potassium restriction is not typically required unless hyperkalemia is present.
B. Provide quiet activities for the child. Edema can cause fatigue, and quiet activities help conserve energy and reduce strain.
C. Weigh the child once a week. Daily weight monitoring is critical to track fluid retention or loss.
D. Administer acetaminophen to the child daily. Acetaminophen is not routinely required unless there is a specific indication, such as fever or pain.

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Correct Answer is B

Explanation

A. Urine output of 50 mL in 2 hr: This is within normal limits for a child and does not indicate an immediate concern.
B. Lethargy: Lethargy is a potential sign of increased intracranial pressure (ICP), which is a critical complication of VP shunt placement and requires immediate intervention.
C. Respiratory rate 24/min: This is within the normal range for a 4-year-old child.
D. Absent Babinski reflex: This is a normal finding in children over 2 years old, as the reflex typically disappears by that age.

A. A 15-year-old client who requires an open reduction of a fracture. B. A 6-month-old infant requiring IV antibiotics. C. 14-year-old client seeking prenatal care. D. A 5-year-old child requiring a chest x-ray.

Correct Answer is A

Explanation

A. A 15-year-old client who requires an open reduction of a fracture. Minors generally require parental or guardian consent for surgical procedures unless emancipated.
B. A 6-month-old infant requiring IV antibiotics. Informed consent from the guardian is required for medical interventions like IV antibiotics in infants.
C. A 14-year-old client seeking prenatal care. Pregnant minors in many jurisdictions are allowed to consent for their own prenatal care without a guardian's approval.
D. A 5-year-old child requiring a chest x-ray. While routine x-rays require parental consent, in an emergency, consent may not be necessary if immediate care is required to stabilize the child.

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A nurse is providing home care instructions to the parents of a child who is in the edema phase of nephrotic syndrome. Which of the following instructions should the nurse include in the teaching?

Nursing Test Bank

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