Which is the most appropriate nursing diagnosis for the child with acute glomerulonephritis?
a. Risk for Injury related to malignant process and treatment
b. Fluid Volume Deficit related to excessive losses
c. Fluid Volume Excess related to decreased plasma filtration
d. Fluid Volume Excess related to fluid accumulation in tissues and third spaces
ANS: C
Glomerulonephritis has a decreased filtration of plasma, which results in an excessive accumulation of water and sodium that expands plasma and interstitial fluid volumes, leading to circulatory congestion and edema. No malignant process is involved in acute glomerulonephritis. A fluid volume excess is found. The fluid accumulation is secondary to the decreased plasma filtration.
You might also like to view...
What statement by the patient leads the nurse to believe that he needs additional instruction regarding his nasal decongestant?
A) "I will blow my nose before instilling the nasal spray." B) "I will report any dizziness, drowsiness, or rapid pulse." C) "I will drink 2,000 to 3,000 mL of fluid daily." D) "I will use it only when I have nasal discharge."
The nurse is discussing the advantages over-the-counter (OTC) medications with a client. Which statements are disadvantages of OTC drugs versus prescription drugs?(Select all that apply.)
Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. OTC drugs can react with foods, herbal products, and prescriptions, or with other OTC drugs. 2. A client can obtain OTC drugs more easily than prescription drugs. 3. Self-treatment is sometimes ineffective. 4. Choosing the proper medication for a specific problem can be challenging. 5. OTC drugs are more expensive than prescription drugs.
The nurse is changing a 2-month-old client's diaper and notes the client feels warm to touch. Which is the best method for checking this baby's temperature?
A. Oral B. Rectal C. Axillary D. Tympanic membrane
The parent of an infant with nasopharyngitis should be instructed to notify the health professional if the infant displays which clinical manifestation?
a. Fussiness b. Coughing c. A fever over 99° F d. Signs of an earache