A child with acute glomerulonephritis is in the playroom, and experiences blurred vision and headache. Which action should be taken by the nurse?
1. Check the urine to see if hematuria has increased.
2. Obtain a blood pressure reading on the child and notify the physician.
3. Reassure the child and encourage bedrest until the headache improves.
4. Obtain serum electrolytes and send urinalysis to the lab.
2
Rationale: This is a serious complication, and delay in treatment could mean lethargy and seizures. Therefore, the other options (checking urine for hematuria, encouraging bedrest, and obtaining serum electrolytes) do not directly address the potential problem of encephalopathy.
1. This is a serious complication, and delay in treatment could mean lethargy and seizures. Therefore, checking urine for hematuria does not directly address the potential problem of encephalopathy.
2. Blurred vision and headache can be signs of encephalopathy, a complication of acute glomerulonephritis. The nurse should obtain a blood pressure and notify the physician. The physician might decide to order an antihypertensive to lower the BP.
3. This is a serious complication, and delay in treatment could mean lethargy and seizures. Therefore, reassuring the child and encouraging bedrest do not directly address the potential problem of encephalopathy.
4. This is a serious complication, and delay in treatment could mean lethargy and seizures. Therefore, obtaining serum electrolytes and sending urinalysis to the lab do not directly address the potential problem of encephalopathy.
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