The nurse is reviewing the Nurses' Notes. Vital Signs, and Laboratory Results from week 2 at 1200.
Click to highlight the findings that indicate the child's prescribed therapy has been effective. To deselect a finding, click on the finding again.
Nurses' Notes
Week 2, 1200:
Child is back at the provider's office for a follow-up appointment following discharge from the hospital. Child was discharged with a prescription for oral prednisone. Child states they feel better, but the medication makes them feel different. Skin warm to the touch. Skin turgor without tenting. Capillary refill less than 2 seconds. Periorbital area without edema. Bowel sounds active in all 4 quadrants. Last bowel movement 1 day ago soft and formed. Child reports no pain with urination. Nonpitting edema noted in lower extremities.
Vital Signs
Week 2, 1200:
- Temperature 38.8° C (101.8° F)
- Heart rate 90/min
- Respiratory rate 18/min
- Blood pressure 140/76 mm Hg
Skin turgor without tenting
Capillary refill less than 2 seconds.
Periorbital area without edema.
Last bowel movement 1 day ago soft and formed.
Nonpitting edema noted in lower extremities.
Temperature 38.8° C (101.8° F)
Blood pressure 140/76 mm Hg
The Correct Answer is ["A","B","C","D"]
The evaluation of therapeutic effectiveness in Minimal Change Nephrotic Syndrome (MCNS) focuses on the reversal of the core pathological symptoms: edema and fluid shifts. Effective corticosteroid therapy (Prednisone) repairs the glomerular basement membrane, stopping the leakage of protein into the urine. As serum albumin levels rise, fluid moves from the tissues back into the vascular space, leading to improved peripheral perfusion, resolution of edema, and normalization of hydration status.
Rationale for correct findings:
• Improved skin turgor indicates better hydration status and restoration of intravascular volume. Initially, the child had skin tenting, suggesting dehydration despite edema from fluid shifting into interstitial spaces. Resolution of tenting shows that fluid balance is improving and circulating volume is more stable. This is an important sign that treatment is helping correct nephrotic fluid imbalance.
• A capillary refill of less than 2 seconds reflects normal peripheral perfusion and improved circulation. Previously, delayed capillary refill suggested poor intravascular volume and decreased tissue perfusion. Improvement indicates better vascular filling and more effective fluid management. This supports that the prescribed therapy is successfully improving circulatory status.
• Resolution of periorbital edema is a strong indicator that excess fluid retention is decreasing. Periorbital swelling is a classic early sign of nephrotic syndrome caused by hypoalbuminemia and fluid leakage into tissues. Its absence suggests reduced protein loss and better fluid regulation. This finding strongly supports therapeutic improvement.
• A soft, formed bowel movement indicates improvement from the previous loose, liquid stools and hyperactive bowel sounds. This suggests better gastrointestinal function, improved nutritional intake, and reduced fluid loss from diarrhea. Stabilization of bowel patterns helps support hydration and overall recovery. It reflects improved systemic status after treatment.
Rationale for incorrect findings:
• The presence of any edema suggests that fluid retention has not completely resolved. Although nonpitting edema may be less severe than previous pitting edema, it still indicates persistent abnormal fluid accumulation. Full therapeutic effectiveness would ideally show resolution of edema rather than its continued presence. This finding requires continued monitoring rather than being considered a clear success.
• An elevated temperature is concerning and does not indicate improvement. Fever may suggest infection, which is especially important because prednisone therapy suppresses immune function. Children receiving corticosteroids are at increased risk for infection and require close observation. This finding suggests a possible complication rather than effective therapy.
• This blood pressure is elevated for a 7-year-old child and is concerning rather than reassuring. Hypertension may result from steroid therapy, fluid retention, or renal complications. It does not indicate successful resolution of nephrotic syndrome and may require further evaluation. Elevated blood pressure should be followed closely rather than considered a sign of effective treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Fall risk in pediatric clients is influenced by age, mobility, developmental stage, and conditions that affect balance, coordination, or vision. Toddlers are already at increased risk for falls because of developing motor skills, curiosity, and limited safety awareness. When a visual disturbance such as strabismus is present, depth perception and coordination may be impaired further. Nurses must identify children with the greatest fall risk to implement appropriate safety precautions and prevent injury.
Rationale:
A. An infant who has constipation is not at significant increased risk for falls because infants have limited independent mobility and are usually closely supervised. Constipation may cause discomfort or irritability, but it does not directly impair balance, vision, or ambulation. Therefore, it is not considered a major fall-risk factor.
B. A child who has asthma may require monitoring for respiratory distress, but asthma itself does not directly increase fall risk unless severe weakness or medication side effects are present. The condition mainly affects airway function rather than coordination or balance. Without additional complications, asthma is not the highest fall-risk diagnosis.
C. An adolescent who has neutropenia is at increased risk for infection rather than falls. Neutropenia reflects low neutrophil levels and requires infection prevention measures such as limiting exposure to pathogens. It does not inherently affect gait, vision, or motor coordination, so fall risk is not the primary concern.
D. A toddler who has strabismus is at greater risk for falls because misalignment of the eyes can interfere with depth perception and visual coordination. Toddlers are already prone to falls due to active exploration and immature motor control, and impaired vision increases this risk further. This combination makes fall prevention a priority for safety.
Correct Answer is D
Explanation
Safe medication administration in pediatric clients requires strict adherence to patient identification protocols to prevent medication errors. Toddlers are unable to reliably identify themselves, so nurses must use approved identifiers before giving any medication. Standard practice involves using at least two unique identifiers such as the identification band and medical record information. Verification must be objective, accurate, and independent of room location or assumptions made by staff or family members.
Rationale:
A. Asking another nurse to confirm the toddler’s identity does not replace the nurse’s responsibility to use approved identifiers. While double-checking may be helpful in some situations, identification must be based on objective sources such as the ID band and medical record. Relying only on another nurse increases the risk of assumption-based errors.
B. Asking the parent to confirm the toddler’s identity can be supportive but should not be the primary identification method. Parents may be distracted, stressed, or unfamiliar with formal identification details used in the medical record. Safe practice requires verification using institutional identifiers rather than relying solely on verbal confirmation from family members.
C. Checking the toddler’s room number against the ID band is unsafe because room numbers are not approved patient identifiers. Clients may be transferred, rooms may be reassigned, and relying on location increases the risk of medication errors. Room number should never be used as a primary method for patient identification.
D. Checking the toddler’s ID band against the medical record is the correct action because it uses reliable and institution-approved identifiers. The ID band contains unique information such as the child’s full name and medical record number, which should match the medication administration record. This method ensures the medication is given to the correct child and supports patient safety standards.
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