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
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Nursing Elites

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?

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 a priority intervention for an infant with a temporary colostomy for Hirschsprung disease?

Correct answer: B

Rationale: Protecting the skin around the colostomy is crucial to prevent irritation and infection, which are common complications in infants with colostomies. Teaching and discussing long-term implications are important but secondary to immediate skin care needs.

3. Latex allergy is suspected in a child with spina bifida. What are appropriate nursing interventions to include in care of this patient?

Correct answer: A

Rationale: The correct answer is A: 'Avoid using any latex product.' In the case of a suspected latex allergy, it is crucial to prevent exposure to latex products to avoid allergic reactions. Choice B is incorrect because there are no truly non-allergenic latex products. Choice C is irrelevant to the situation described in the question, as the child does not have asthma. Choice D is also incorrect because desensitization is not an immediate option for managing a suspected latex allergy.

4. Which of the following conditions is characterized by a 'machine-like' murmur in children?

Correct answer: A

Rationale: The correct answer is A, Patent ductus arteriosus. This condition is characterized by a continuous 'machine-like' murmur due to abnormal blood flow between the aorta and pulmonary artery. Ventricular septal defect (choice B) is characterized by a harsh holosystolic murmur, atrial septal defect (choice C) typically presents with a fixed split S2 and a pulmonary flow murmur, and coarctation of the aorta (choice D) is associated with a systolic murmur in the back and bilateral lower extremities.

5. The nurse is planning care for a patient with a different ethnic background. Which should be an appropriate goal?

Correct answer: A

Rationale: Adapting ethnic practices to health needs respects the patient's cultural background while ensuring that care is effective and culturally sensitive.

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