When caring for a child with glomerulonephritis, what key assessments should the nurse prioritize? (Select All that Apply.)
Assessing joint mobility
Checking visual acuity during the admission interview
Vital signs and neurological status especially with edema
Urine volume and character
Measuring blood glucose levels
Evaluating tolerance of a regular diet with possible restrictions if oliguric
Weigh child same time each day (same scale)
Correct Answer : C,D,F,G
A. Assessing joint mobility is not a priority for glomerulonephritis. This condition primarily affects the kidneys, not the musculoskeletal system.
B. Checking visual acuity is not a key assessment in glomerulonephritis, though periorbital edema may cause puffiness around the eyes, vision itself is not the focus of concern.
C. Monitoring vital signs and neurological status is crucial. Hypertension is a common complication of glomerulonephritis due to sodium and fluid retention. Severe hypertension can also cause neurological changes such as headache, irritability, or seizures, so frequent assessments are necessary.
D. Assessing urine volume and character is a priority. Children may have hematuria (cola- or tea-colored urine), proteinuria, or oliguria. Monitoring urine helps determine kidney function and progression of the disease.
E. Measuring blood glucose levels is not directly related to glomerulonephritis unless the child has a concurrent diagnosis such as diabetes mellitus.
F. Evaluating the child’s tolerance of diet is important. With oliguria, there may be a need for fluid, sodium, or potassium restrictions to prevent worsening fluid overload or electrolyte imbalances. The nurse should ensure the child’s nutritional needs are met within prescribed limits.
G. Daily weights using the same scale, at the same time each day, in similar clothing, provide the most accurate measure of fluid balance. Even small weight changes can indicate significant fluid retention, which is more sensitive than intake and output measurements alone.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Persistent primitive reflexes (such as the Moro, tonic neck, or grasp reflex) are a hallmark finding in young children with cerebral palsy. Normally, these reflexes disappear as the nervous system matures. Their persistence indicates delayed or abnormal neurological development, which is common in cerebral palsy.
B. Children with cerebral palsy often demonstrate abnormal muscle tone, which may be spastic (increased tone), hypotonic (low tone), or fluctuate between both. Normal tone is not expected.
C. Symmetrical, well-coordinated movements are typically impaired. Children may show asymmetry, abnormal posture, or involuntary movements.
D. Gross motor skill development is often delayed or abnormal due to impaired muscle coordination and tone.
Correct Answer is C
Explanation
A. Providing support for the back and spine is not the purpose of the Pavlik harness. It is specifically designed for hip stabilization, not spinal conditions.
B. Immobilizing the legs and preventing movement is not accurate. The Pavlik harness allows limited movement while maintaining the hips in proper alignment; complete immobilization is not intended.
C. Holding the hips in a flexed and abducted position is the primary purpose of the Pavlik harness. This position keeps the femoral head well-seated in the acetabulum, promotes normal hip joint development, and prevents long-term complications associated with developmental dysplasia of the hip (DDH).
D. Correcting scoliosis in infants is unrelated. A Pavlik harness is not used for spinal deformities.
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