Nursing Elites

1. A preschool-age child is admitted to the hospital with acute postinfectious glomerulonephritis (APIGN). Which is the priority nursing diagnosis for this child?

• A. Risk for Injury related to hypertension.
• B. Altered Growth and Development related to chronic disease.
• C. Risk for Infection related to hypertension.
• D. Fluid Volume Excess related to decreased plasma filtration.

Correct answer: A

Rationale: The priority nursing diagnosis for a preschool-age child with acute postinfectious glomerulonephritis (APIGN) is 'Risk for Injury related to hypertension' due to the potential complications such as hypertensive encephalopathy. Hypertension poses an immediate threat to the child's well-being, making it crucial to address the risk for injury associated with elevated blood pressure as the top priority.

2. A nurse is planning care to address nutritional needs for a preschooler with cystic fibrosis. Which interventions should the nurse include in plans?

• A. Administer pancreatic enzymes 2 hours after meals.
• B. Monitor and adjust the use of pancreatic enzymes if steatorrhea develops.
• C. Encourage adequate fluid intake based on the child's needs.
• D. Increase fat content in the child's diet to 40% of total calories.

Correct answer: D

Rationale: Increasing fat content in the diet is essential for meeting the high energy needs of a child with cystic fibrosis. Cystic fibrosis impairs the absorption of nutrients, particularly fats, so increasing the fat content in the child's diet to 40% of total calories helps ensure adequate caloric intake. This intervention can help maintain the child's nutritional status and support growth and development.

3. What is an initial sign of nephrosis that the nurse might note in a child?

• A. Raspberry-like rash
• B. Periorbital edema
• C. Temperature elevation
• D. Abdominal pain

Correct answer: B

Rationale: In nephrotic syndrome, edema is a common symptom that is generalized and not easily noticeable, even by parents. However, an early sign that can be assessed by the nurse is periorbital edema, which refers to swelling around the eyes. This can be an initial indicator of nephrosis and may prompt further evaluation and intervention.

4. What is an appropriate intervention for the edematous child with reduced mobility related to nephrotic syndrome?

• A. Assist the child in minimizing body movements.
• B. Change the child's position frequently.
• C. Maintain the child's bed flat.
• D. Keep edematous areas moist and covered.

Correct answer: B

Rationale: Changing the child's position frequently is essential for preventing respiratory tract infections and reducing pressure on delicate skin, which are common risks for edematous children with reduced mobility due to nephrotic syndrome. This intervention helps promote circulation and prevents complications associated with prolonged immobility.

5. Which food should be avoided by a child with acute glomerulonephritis to prevent hyperkalemia, as recommended by the nurse?

• A. Dairy products
• B. Whole-grain cereals
• C. Organ meats
• D. Bananas

Correct answer: D

Rationale: Bananas are rich in potassium, which can contribute to hyperkalemia in individuals with acute glomerulonephritis. It is essential to limit potassium intake to prevent further complications associated with high potassium levels in the blood.

Similar Questions