An eight-year-old with nephrotic syndrome is pale, lethargic, and has ascites. To determine if the ascites is increasing, the nurse should (chose one best answer):
assess the bowel sounds
Frequently ambulate child
Weigh child weekly
monitor and measure the abdominal girth
The Correct Answer is D
A. Assess the bowel sounds:
Bowel sounds are not directly related to the assessment of ascites. Bowel sounds are more relevant in assessing gastrointestinal function and peristalsis. While bowel changes could potentially be a sign of complications, monitoring abdominal girth is more specific to tracking ascites.
B. Frequently ambulate child:
While ambulation is important for overall health, it's not a direct assessment method for monitoring ascites. Ambulating a child might have benefits, but it won't provide specific information about the presence or progression of ascites.
C. Weigh child weekly:
Weekly weighing can provide some information about overall fluid balance, but it might not be as sensitive as measuring abdominal girth when it comes to detecting changes in ascites. Additionally, monitoring weight alone might not give insight into the distribution of fluid in the abdominal cavity.
D. Monitor and measure the abdominal girth.
Explanation: The presence of ascites (accumulation of fluid in the abdominal cavity) in a child with nephrotic syndrome could indicate worsening kidney function and fluid balance. Monitoring and measuring the abdominal girth is a reliable way to assess changes in the amount of fluid accumulation over time. An increase in abdominal girth could suggest a worsening condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Position the child laterally
Explanation: When a child is experiencing a seizure, it's important to ensure their safety and prevent injury. Positioning the child laterally, also known as the recovery position, helps keep the airway clear and allows any fluids to drain from the mouth, reducing the risk of aspiration. It also helps prevent the child from choking on saliva or vomit.
The other options are not appropriate actions during a seizure:
B. Using a padded tongue blade is not recommended during a seizure. Placing objects in the mouth during a seizure can lead to injury, including damage to the teeth, jaw, or airway.
C. Attempting to stop the seizure is not within the nurse's control. Seizures are caused by abnormal electrical activity in the brain and should not be interrupted forcefully. Instead, the focus should be on ensuring the child's safety and managing the situation until the seizure stops on its own.
D. Restraining the child's arms is not advisable during a seizure. Restraining can cause harm and increase the risk of injury to the child or others involved. It's important to allow the seizure to run its course while protecting the child from harm.
Correct Answer is D
Explanation
A) "I can store unopened bottles of insulin in the freezer."
This statement is incorrect. Insulin should not be stored in the freezer. Insulin should be stored in the refrigerator, and the currently used vial can be kept at room temperature for up to 28 days to avoid the discomfort of injecting cold insulin.
B) "I should not take my regular insulin when I am sick."
This statement is incorrect. When a person with type 1 diabetes is sick, it's important to continue taking insulin. In fact, during illness, blood sugar levels can become more difficult to manage, and insulin may be needed in adjusted doses. Skipping insulin during sickness can lead to uncontrolled blood sugar levels and potentially worsen the illness.
C) "My morning blood glucose should be between 90 and 130."
This statement is a good range to aim for in terms of fasting blood glucose levels, but it's not an indication of understanding the teaching about diabetes management as a whole. While this knowledge is important, the statement about eating a snack before playing soccer directly reflects understanding of how to manage blood sugar during physical activity.
"D) I should eat a snack half an hour before playing soccer."
Explanation:
Managing blood sugar levels is crucial for individuals with type 1 diabetes, especially when engaging in physical activities like playing soccer. Eating a snack before playing helps prevent hypoglycemia (low blood sugar) during exercise. Physical activity can cause the body to use up glucose faster, potentially leading to low blood sugar levels, and having a snack before exercise can help maintain stable blood sugar levels.
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