Nokea
The infant has a diagnosis of bladder exstrophy. To protect the exposed bladder tissue, what intervention should the nurse plan?
- A. Cover the bladder with petroleum jelly gauze.
- B. Cover the bladder with a non-adhering plastic wrap.
- C. Apply sterile distilled water dressings over the bladder mucosa.
- D. Keep the bladder tissue dry by covering it with dry sterile gauze.
Correct Answer: C
Rationale: Bladder exstrophy is a condition where the bladder is exposed and external to the body. To protect the exposed bladder tissue from drying out while allowing urine drainage, it is best to cover the bladder with a non-adhering plastic wrap. Using petroleum jelly gauze should be avoided as it can dry out, adhere to the mucosa, and damage delicate tissue upon removal. Applying sterile distilled water dressings can also dry out and cause damage when removed. Keeping the bladder tissue dry with sterile gauze is not ideal as maintaining a moist environment is important for tissue protection in this case.
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A 4-year-old child with acute glomerulonephritis is admitted to the hospital. The nurse identifies which client problem in the plan of care as the priority?
- A. Infection related to hypertension
- B. Injury related to loss of blood in urine
- C. Excessive fluid volume related to decreased plasma filtration
- D. Retarded growth and development related to a chronic disease
Correct Answer: C
Rationale: In acute glomerulonephritis, the child experiences excessive accumulation of water and retention of sodium, leading to circulatory congestion and edema. Excessive fluid volume is a primary concern due to the disease process. Hypertension and infection are not directly related to acute glomerulonephritis; therefore, they are not the priority client problems. While hematuria (blood in urine) may occur, it typically does not lead to significant injury that takes precedence over excessive fluid volume. Acute glomerulonephritis is an acute condition, not chronic; therefore, retarded growth and development related to a chronic disease is not the priority issue. With proper management, most children recover completely without long-term growth and development issues.
The nurse is collecting data on a child recently diagnosed with glomerulonephritis. Which question to the mother should elicit data associated with the cause of this disease?
- A. Has your child had any nausea or diarrhea?''
- B. Have you noticed any rashes on your child?''
- C. Did your child recently complain of a sore throat?''
- D. Did your child sustain any injuries to the kidney area?''
Correct Answer: C
Rationale: The correct answer is 'Did your child recently complain of a sore throat?' Group A beta-hemolytic streptococcal infection is a known cause of glomerulonephritis. In this condition, the child typically becomes ill with streptococcal infection of the upper respiratory tract, and then after 1 to 2 weeks, symptoms of acute poststreptococcal glomerulonephritis can develop. This question aims to gather crucial information related to a potential trigger for glomerulonephritis. Choices A, B, and D are incorrect because they do not pertain to a common cause or associated symptom of glomerulonephritis.
A patient with a cast on the right leg is being cared for by a nurse. Which of the following assessment findings would be most concerning for the nurse?
- A. The capillary refill time is 2 seconds
- B. The patient complains of itching and discomfort
- C. The cast has a foul-smelling odor
- D. The patient is on antibiotics
Correct Answer: C
Rationale: A foul-smelling odor emanating from the cast is a concerning finding as it indicates the possibility of infection or the presence of a pressure ulcer. These conditions can lead to serious complications if not promptly addressed. It is crucial for the nurse to investigate further and take appropriate actions to prevent potential harm to the patient. The other options do not directly indicate a risk of infection or complications associated with the cast. Itching and discomfort are common complaints due to wearing a cast, and the patient being on antibiotics may be part of their treatment plan for an unrelated condition. Capillary refill time of 2 seconds is within the normal range and would not be a cause for immediate concern in this scenario.
A client with Multiple Sclerosis reports a constant, burning, tingling pain in the shoulders. The nurse anticipates that the physician will order which medication for this type of pain?
- A. alprazolam (Xanax)
- B. Corticosteroid injection
- C. gabapentin (Neurontin)
- D. hydrocodone/acetaminophen (Norco)
Correct Answer: C
Rationale: For neuropathic pain associated with conditions like Multiple Sclerosis, medications like gabapentin, an anticonvulsant, are commonly used. Gabapentin helps in managing nerve pain by stabilizing electrical activity in the brain and nervous system. Alprazolam is a benzodiazepine used for anxiety and not primarily indicated for neuropathic pain. Corticosteroid injections are more suitable for inflammatory conditions like arthritis, not for neuropathic pain. Hydrocodone/acetaminophen is an opioid combination used for moderate to severe pain, but it is not the first-line choice for neuropathic pain.
The nurse is caring for a 7-year-old child with glomerulonephritis and is preparing to discuss the plan of care with the parents. In anticipating this encounter, the nurse recognizes that which is a common reaction of parents to the diagnosis of glomerulonephritis?
- A. Fear of the complicated treatment regimen
- B. Anger at the child for requiring hospitalization
- C. Guilt that they did not seek treatment more quickly
- D. Depression that the child may not be able to play sports
Correct Answer: C
Rationale: Guilt is a common reaction of parents when their child is diagnosed with glomerulonephritis. Parents often blame themselves for not responding promptly to the child's initial symptoms or feel guilty for not seeking treatment sooner, thinking they could have prevented the development of glomerular damage. While fear of a complicated treatment regimen, anger at the child for hospitalization, and depression about the child not playing sports may be valid concerns, they are generally not as commonly observed as the feeling of guilt among parents in this situation.