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 B
Explanation
Choice A reason: Consents for surgery involve legal and procedural details, typically handled by providers, not nurses. Educating on growth and development is within nursing scope, making this incorrect, as it exceeds the nurse’s role in instructing families of a child with a chronic illness.
Choice B reason: Instructing on growth and development changes helps parents understand their child’s progress despite chronic illness, within the nurse’s educational role. This aligns with pediatric nursing practice, making it the correct situation for the nurse to provide instruction in the pediatrician’s office.
Choice C reason: Explaining diagnostic tests and lab work is typically the provider’s responsibility, as it involves medical interpretation. Growth and development education is nurse-appropriate, making this incorrect, as it falls outside the nurse’s primary instructional role for the chronically ill child’s family.
Choice D reason: Diagnosing secondary problems is a medical responsibility, not within nursing scope for instruction. Growth and development guidance is nurse-led, making this incorrect, as it involves diagnostic communication beyond the nurse’s role in educating the family of the chronically ill child.
Correct Answer is C
Explanation
Choice A reason: Bone marrow transplant is reserved for high-risk or relapsed ALL, not routine across treatment phases. Complete remission is the goal periodically assessed, making this incorrect, as it’s not a standard periodic occurrence in the child’s treatment for acute lymphoblastic leukemia.
Choice B reason: Relapse is a complication, not an expected periodic outcome in ALL treatment phases. Complete remission is regularly evaluated, making this incorrect, as it represents a failure rather than the anticipated progress in the child’s ongoing leukemia treatment protocol.
Choice C reason: Complete remission, marked by no detectable leukemia cells, is the goal periodically assessed during ALL treatment phases. This aligns with pediatric oncology protocols, making it the correct outcome most likely seen as the child progresses through treatment for acute lymphoblastic leukemia.
Choice D reason: Methotrexate injections into cerebrospinal fluid are specific to central nervous system prophylaxis, not periodic across all phases. Complete remission is routinely monitored, making this incorrect, as it’s not a universal periodic event in the child’s ALL treatment process.
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