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 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.
Correct Answer is B
Explanation
A. Can always track an object with eyes:
The ability to track an object with the eyes typically develops in infants around 2 to 3 months of age. This developmental milestone is not specific to cerebral palsy and is generally expected in healthy infants.
B. Needs support with pillow props for sitting
Explanation:
Cerebral palsy (CP) is a group of permanent movement disorders that appear in early childhood. It is caused by abnormal development or damage to the parts of the brain that control movement, balance, and posture. The symptoms of cerebral palsy can vary widely, but they are generally related to motor function and coordination.
The manifestation of needing support with pillow props for sitting is consistent with the motor impairments often seen in cerebral palsy. Children with cerebral palsy may have difficulties with muscle control and coordination, which can affect their ability to sit independently. The need for external support to maintain a sitting position is indicative of motor developmental delays or challenges associated with cerebral palsy.
C. Uses a pincer grasp to pick up a toy:
The pincer grasp, where a child uses the thumb and index finger to pick up small objects, usually develops around 9 to 12 months of age. This developmental milestone is not directly associated with cerebral palsy and is part of normal infant development.
D. Smiles when a parent appears:
Smiling in response to familiar faces, including parents, is a social and emotional developmental milestone that typically occurs around 2 to 3 months of age. While cerebral palsy can affect motor function, it does not directly impact an infant's ability to express emotions like smiling.
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