A child diagnosed with acute glomerulonephritis is in the playroom and experiences blurred vision and headache. Which action by the nurse is the most appropriate?
1. Check the urine to see if hematuria has increased.
2. Obtain a blood pressure on the child; notify the healthcare provider.
3. Reassure the child, and encourage bed rest until the headache improves.
4. Obtain serum electrolytes, and send a urinalysis to the lab.
Correct Answer: 2
Rationale: Blurred vision and headache may be signs of encephalopathy, a complication of acute glomerulonephritis. A blood pressure (BP) should be obtained and the healthcare provider notified. The healthcare provider may decide to order an antihypertensive to bring down the BP. This is a serious complication, and delay in treatment could mean lethargy and seizures. Therefore, the other options (checking urine for hematuria, encouraging bed rest, and obtaining serum electrolytes) do not directly address the potential problem of encephalopathy.
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