The caregiver of a child being treated at home for acute glomerulonephritis calls the nurse reporting that her daughter has just had a convulsion. The child is resting comfortably but the caregiver would like to know what to do. The nurse would instruct the caregiver to take which action?
Weigh the child in the same clothes she had been weighed in the day before and report the two weights to the nurse while the nurse is on the phone.
Give the child fluids and report back to the nurse in a few hours.
Give the child a diuretic and report back to the nurse in a few hours.
Take the child’s blood pressure and report the findings to the nurse while the nurse is still on the phone.
The Correct Answer is D
Choice A reason: Weighing the child monitors fluid retention but is less urgent than blood pressure, which assesses hypertensive encephalopathy risk post-convulsion in glomerulonephritis. Immediate blood pressure data guides treatment, making this secondary and incorrect compared to evaluating the child’s neurological status after a seizure.
Choice B reason: Giving fluids without guidance risks worsening fluid overload in glomerulonephritis, and delayed reporting is unsafe post-convulsion. Blood pressure assessment is critical, making this inappropriate and incorrect compared to the urgent need for immediate data to address the child’s seizure episode effectively.
Choice C reason: Administering a diuretic without provider orders is unsafe post-convulsion, as it may not address the seizure’s cause. Blood pressure evaluation informs treatment, making this risky and incorrect compared to the priority of assessing hypertension in the child with glomerulonephritis immediately.
Choice D reason: Taking blood pressure post-convulsion assesses for hypertension, a common seizure cause in glomerulonephritis, guiding urgent treatment. Reporting immediately ensures timely intervention, aligning with pediatric nephrology protocols, making this the correct action for the caregiver to take in this emergency situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Lack of eye contact and developmental delay don’t directly indicate physical abuse, which typically shows fear or physical signs. Autistic behaviors like poor eye contact are more likely, making this incorrect, as the toddler’s behaviors align better with autism in the well-child assessment.
Choice B reason: Cocaine abuse by the caregiver might affect development but isn’t linked to specific behaviors like poor eye contact. Autistic traits better explain the toddler’s symptoms, making this speculative and incorrect compared to the nurse’s assessment of developmental concerns in the child.
Choice C reason: Poor eye contact and slower development at 23 months suggest autistic behaviors, common in autism spectrum disorder. This aligns with pediatric developmental screening, making it the correct additional assessment for the nurse to consider based on the toddler’s observed behaviors during the check.
Choice D reason: ADHD typically presents later with hyperactivity and inattention, not poor eye contact or developmental delay at 23 months. Autistic behaviors are more fitting, making this incorrect, as the toddler’s symptoms align better with autism than ADHD in the well-child evaluation.
Correct Answer is D
Explanation
Choice A reason: Asking the child about seeing her mother places an unfair burden on her, especially post-accident when she may be distressed. Verifying legal contact permissions ensures compliance with custody agreements, making this inappropriate and incorrect compared to confirming authorized visitors in this sensitive situation.
Choice B reason: Directing the mother to the room without checking custody status risks violating legal restrictions, potentially escalating conflict. Confirming who is allowed contact protects the child, making this hasty and incorrect compared to the nurse’s responsibility to verify permissions in a divorce-related hospital scenario.
Choice C reason: Asking the mother about her permission may be unreliable, as agitation could lead to inaccurate claims. Checking official records ensures adherence to custody orders, making this inadequate and incorrect compared to the nurse’s duty to verify authorized contact for the hospitalized child objectively.
Choice D reason: Checking who is allowed contact verifies legal custody arrangements, ensuring the child’s safety and compliance with court orders in a divorce situation. This aligns with pediatric hospital protocols, making it the most appropriate action to address the mother’s demand while protecting the injured daughter.
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