A 4-year-old has acute glomerulonephritis, and is admitted to the hospital. An appropriate nursing diagnosis for this child would be:
1. Injury, risk for related to loss of blood in urine.
2. Fluid Volume Excess related to decreased plasma filtration.
3. Infection, risk for related to hypertension.
4. Altered Growth and Development related to a chronic disease.
2
Rationale:
1. There is no risk for injury, because the blood loss in the urine is not sufficient to cause anemia.
2. The fluid is excessive, and fluid and electrolyte balance should be monitored.
3. While a risk for infection might be present, it is not related to the hypertension.
4. Growth and development are not normally affected, because this is an acute process, not a chronic one.
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When providing an infant with a gavage feeding, which of the following should be documented each time?
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A patient is describing a very personal part of her history very quickly and in great detail. How should you react to this?
A) Write down as much as you can, as quickly as possible. B) Ask her to repeat key phrases or to pause at regular intervals, so you can get almost every word. C) Tell her that she can go over the notes later to make sure they are accurate. D) Push away from the keyboard or put down your pen and listen.