What is the priority action the nurse will take for a 4-year old client admitted with minimal change nephrotic syndrome (MCNS) who has hypertension and facial edema?

Monitor the client's fluid volume and hydration status.

Teaching the client's parents about and preparing for a renal biopsy.

Consulting with a registered dietician about adequate intake.

Use only sterile techniques to prevent infections.

Answer and Explanation

The Correct Answer is A

In a client with minimal change nephrotic syndrome (MCNS), the primary concern is the management of fluid volume and hydration status. MCNS is characterized by increased glomerular permeability, leading to excessive protein loss in the urine and subsequent hypoalbuminemia. This can result in fluid retention and edema formation, including facial edema.

Hypertension is a common complication in clients with MCNS, and it further contributes to fluid retention and potential complications. Therefore, closely monitoring the client's fluid volume and hydration status, including daily weights, intake and output measurements, and assessment of edema, is crucial to detect any changes and guide appropriate interventions.

While other actions, such as consulting with a registered dietitian about adequate intake or using sterile technique to prevent infections, may be important aspects of the client's care, they are not the priority in this situation. The immediate concern is managing the client's hypertension and fluid volume status to prevent complications associated with MCNS.

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Correct Answer is D

Explanation

Compartment syndrome is a condition characterized by increased pressure within a muscle compartment, leading to impaired blood flow and potential tissue damage. It can occur when swelling or bleeding within a confined space, such as a cast, causes increased pressure on the surrounding tissues.

Tingling in the toes and decreased sensation can be indicative of nerve compression or damage due to increased pressure in the compartment. It is important to recognize these neurological changes as potential signs of compartment syndrome.

Signs and symptoms of compartment syndrome may include:

Severe pain that is out of proportion to the injury or not relieved by pain medication.
Swelling and tightness in the affected area.
Numbness or tingling.
Pale or cool skin over the affected area.
Weakness or decreased sensation in the affected limb.
In severe cases, paralysis or loss of pulse in the affected area.

A. A 50-yr-old patient who uses exenatide (Byetta) and is complaining of acute abdominal pain B. A 23-yr-old patient with type 1 diabetes who has a blood glucose of 40 mg/dL C. A 40-yr-old patient who is pregnant and whose oral glucose tolerance test is 202 mg/dL D. A 19-yr-old patient with type 1 diabetes who has a hemoglobin A1C of 12%

Correct Answer is B

Explanation

A blood glucose level of 40 mg/dL indicates severe hypoglycemia, which is a medical emergency requiring immediate attention. Hypoglycemia can lead to confusion, altered mental status, seizures, and loss of consciousness if not treated promptly. Therefore, it is crucial to assess and intervene quickly to raise the patient's blood glucose level to a safe range.

While the other clients mentioned also require attention and appropriate care, the severity and immediate risk associated with severe hypoglycemia make it the priority situation. The nurse should initiate appropriate treatment for hypoglycemia, such as administering glucose or glucagon, and closely monitor the patient's response.

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What is the priority action the nurse will take for a 4-year old client admitted with minimal change nephrotic syndrome (MCNS) who has hypertension and facial edema?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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