the nurse notes that a child has lost 36 kg 8 lb after 4 days of hospitalization for acute glomerulonephritis what is the most likely cause of this we

ATI RN

RN Nursing Care of Children 2019 With NGN

1. The nurse notes that a child has lost 3.6 kg (8 lb) after 4 days of hospitalization for acute glomerulonephritis. What is the most likely cause of this weight loss?

A. Poor appetite
B. Reduction of edema
C. Restriction to bed rest
D. Increased potassium intake

Correct answer: B

Rationale: The weight loss is most likely due to the reduction of edema, as glomerulonephritis often causes fluid retention that resolves with treatment, leading to significant weight loss.

2. What is the recommended method to assess hydration status in infants?

A. Capillary refill time
B. Skin turgor
C. Urine output
D. Mucous membranes

Correct answer: C

Rationale: The correct answer is C: Urine output. Assessing urine output is a recommended method to determine hydration status in infants. Adequate urine output indicates good hydration, while decreased urine output may suggest dehydration. Capillary refill time (Choice A) is more indicative of circulatory status rather than hydration. Skin turgor (Choice B) is a useful assessment in adults but can be less reliable in infants. Checking mucous membranes (Choice D) can provide some information on hydration, but it is not as reliable as assessing urine output in infants.

3. What laboratory finding should the nurse expect in a child with an excess of water?

A. Decreased hematocrit
B. High serum osmolality
C. High urine specific gravity
D. Increased blood urea nitrogen (BUN)

Correct answer: A

Rationale: Water excess typically leads to hemodilution, resulting in a decreased hematocrit. High serum osmolality and specific gravity would indicate dehydration, while elevated BUN could suggest renal impairment or dehydration, not fluid overload.

4. Superficial palpation of the abdomen is often perceived by the child as tickling. Which measure by the nurse is most likely to minimize this sensation and promote relaxation?

A. Palpate another area simultaneously
B. Ask the child not to laugh or move
C. Begin with deeper palpation and gradually progress to superficial palpation
D. Have the child help with palpation by placing his or her hand over the palpating hand

Correct answer: D

Rationale: Allowing the child to place their hand over the nurse's hand helps reduce the tickling sensation and increases the child's comfort during the examination.

5. What are classified as hydrocarbon poisons?

A. All below
B. Gasoline
C. Turpentine
D. Lighter fluid

Correct answer: A

Rationale: Hydrocarbon poisons include substances like gasoline, turpentine, and lighter fluid, which are typically liquids derived from petroleum. Bleach is a corrosive substance, not a hydrocarbon.