Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A 4-year-old with nephrotic syndrome is experiencing severe periorbital edema. The best measure the nurse could institute to help reduce the periorbital edema is:
A. apply cool sterile soaks to the child's head
Applying cool sterile soaks to the child's head would not directly address periorbital edema. Nephrotic syndrome is a kidney disorder that results in proteinuria (loss of protein in urine), leading to fluid accumulation and edema. Cooling the head would not have a significant impact on reducing periorbital edema caused by nephrotic syndrome.
B. apply warm compresses
Applying warm compresses can help increase blood circulation and promote the reabsorption of excess fluid causing periorbital edema. Warmth can dilate blood vessels and improve the movement of fluids, potentially alleviating the edema.
C. encourages the child to eat low protein foods
While dietary modifications might be part of managing nephrotic syndrome, specifically encouraging low protein foods may not directly address periorbital edema. The primary treatment for nephrotic syndrome involves medications to control proteinuria and manage fluid balance.
D. elevate the head of the bed
Elevating the head of the bed is more commonly used to manage conditions like heart failure or obstructive sleep apnea. It might have some impact on overall fluid distribution, but it's not the most effective measure for reducing periorbital edema caused by nephrotic syndrome.
This question is an excerpt from Nurse Dive's nursing test bank - ATI PAEDIATRICS PROCTORED EXAM - SIMMONS U BSN. Take the full exam now
Full Explanation
A. Apply cool sterile soaks to the child's head.
Explanation: Applying cool sterile soaks to the child's head would not directly address periorbital edema. Nephrotic syndrome is a kidney disorder that results in proteinuria (loss of protein in urine), leading to fluid accumulation and edema. Cooling the head would not have a significant impact on reducing periorbital edema caused by nephrotic syndrome.
B. Apply warm compresses.
Explanation: Correct Choice. Applying warm compresses can help increase blood circulation and promote the reabsorption of excess fluid causing periorbital edema. Warmth can dilate blood vessels and improve the movement of fluids, potentially alleviating the edema.
C. Encourage the child to eat low protein foods.
Explanation: While dietary modifications might be part of managing nephrotic syndrome, specifically encouraging low protein foods may not directly address periorbital edema. The primary treatment for nephrotic syndrome involves medications to control proteinuria and manage fluid balance.
D. Elevate the head of the bed.
Explanation: Elevating the head of the bed is more commonly used to manage conditions like heart failure or obstructive sleep apnea. It might have some impact on overall fluid distribution, but it's not the most effective measure for reducing periorbital edema caused by nephrotic syndrome.
Similar Questions
A nurse is caring for a child who is having a tonic-clonic seizure and vomiting. Which of the following actions is the nurse's priority?
A. Place a pillow under the child's head.
While providing comfort is important, the priority in this scenario is to ensure the child's safety. Placing a pillow under the head can be considered after addressing immediate safety concerns.
B. Clear the area of hazards.
Ensuring the area is clear of hazards is the nurse's priority. During a seizure, the child can experience uncontrolled movements, and having hazards around can lead to injuries. Clearing the area helps prevent harm. But priority is to position the child side lying.
C. Position the child side-lying
Placing the child in a side-lying position helps prevent choking and aspiration due to vomiting during the seizure. It also minimizes the risk of airway obstruction and helps manage secretions.
D. Loosen restrictive clothing
While loosening restrictive clothing can facilitate breathing, the priority in this situation is addressing safety concerns related to the seizure and vomiting. Ensuring a clear and safe environment takes precedence.
Full Explanation
A. Place a pillow under the child's head.
Explanation: While providing comfort is important, the priority in this scenario is to ensure the child's safety. Placing a pillow under the head can be considered after addressing immediate safety concerns.
B. Clear the area of hazards.
Explanation: Correct Choice. Ensuring the area is clear of hazards is the nurse's priority. During a seizure, the child can experience uncontrolled movements, and having hazards around can lead to injuries. Clearing the area helps prevent harm. But priority is to position the child side lying.
C. Position the child side-lying.
Explanation: Correct Choice. Placing the child in a side-lying position helps prevent choking and aspiration due to vomiting during the seizure. It also minimizes the risk of airway obstruction and helps manage secretions.
D. Loosen restrictive clothing.
Explanation: While loosening restrictive clothing can facilitate breathing, the priority in this situation is addressing safety concerns related to the seizure and vomiting. Ensuring a clear and safe environment takes precedence.
What do we include as part of our concussion/head injury prevention teaching to children and parents:
A. Dizziness is always a sign of a concussion
This statement is incorrect. While dizziness can be a symptom of a concussion, it is not always indicative of a concussion. There can be various causes of dizziness, and it is essential to consider other symptoms as well when assessing for a concussion.
B. Bike helmet safety
The correct answer to include as part of concussion/head injury prevention teaching to children and parents is "Bike helmet safety." This is because wearing a helmet while riding a bike or participating in other activities that involve head injury risks is crucial to prevent head injuries and concussions. Helmets provide protection to the head by absorbing impact energy and reducing the risk of skull fractures or traumatic brain injuries.
C. Normal fluid intake
While staying hydrated is important for overall health, it is not directly related to concussion or head injury prevention teaching. This choice is unrelated to the topic.
D. Signs of autism
Signs of autism are unrelated to concussion or head injury prevention teaching. This choice is not relevant to the topic at hand.
Full Explanation
A. Dizziness is always a sign of a concussion.
This statement is incorrect. While dizziness can be a symptom of a concussion, it is not always indicative of a concussion. There can be various causes of dizziness, and it is essential to consider other symptoms as well when assessing for a concussion.
B. Bike Helmet Safety
Explanation:
The correct answer to include as part of concussion/head injury prevention teaching to children and parents is "Bike helmet safety." This is because wearing a helmet while riding a bike or participating in other activities that involve head injury risks is crucial to prevent head injuries and concussions. Helmets provide protection to the head by absorbing impact energy and reducing the risk of skull fractures or traumatic brain injuries.
C. Normal fluid intake.
While staying hydrated is important for overall health, it is not directly related to concussion or head injury prevention teaching. This choice is unrelated to the topic.
D. Signs of autism.
Signs of autism are unrelated to concussion or head injury prevention teaching. This choice is not relevant to the topic at hand.
A nurse is caring for a child who has acute glomerulonephritis. Which of the following actions is the nurse's priority?
A. Maintain a saline-lock.
Maintaining a saline lock is important for potential intravenous access, but it is not the most urgent priority compared to actions that directly monitor the child's condition and help manage the disease.
B. Check the child's day weight
Monitoring daily weight is crucial in acute glomerulonephritis, as it helps assess fluid balance and detect early signs of fluid retention or worsening kidney function, which are key concerns in this condition. This makes it a priority action.
C. Place the child on a no-salt-added diet.
While dietary modifications can be important for managing various health conditions, including kidney issues, this is not the top priority in this situation. Reducing salt intake can help manage fluid retention, but it is not the nurse's priority action at this moment.
D. Educate the parents about potential complications
Patient education is crucial, especially in chronic conditions, but in this acute care scenario, the nurse's immediate priority is to address the child's needs. Educating parents about potential complications should be done, but it's not the most immediate action.
Full Explanation
A. Maintain a saline-lock:
Maintaining a saline lock is important for potential intravenous access, but it is not the most urgent priority compared to actions that directly monitor the child's condition and help manage the disease.
B. Check the child's daily weight:
Monitoring daily weight is crucial in acute glomerulonephritis, as it helps assess fluid balance and detect early signs of fluid retention or worsening kidney function, which are key concerns in this condition. This makes it a priority action.
C. Place the child on a no-salt-added diet:
While dietary modifications can be important for managing various health conditions, including kidney issues, this is not the top priority in this situation. Reducing salt intake can help manage fluid retention, but it is not the nurse's priority action at this moment.
D. Educate the parents about potential complications:
Patient education is crucial, especially in chronic conditions, but in this acute care scenario, the nurse's immediate priority is to address the child's needs. Educating parents about potential complications should be done, but it's not the most immediate action.