Exercise:
1、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 thepriority?
1.Infection related to hypertension
2.Injury related to loss of blood in urine
3.Excessive fluid volume related to decreased plasma filtration
4.Retarded growth and development related to a chronic disease
Correct Answer:3
Glomerulonephritis is a term that refers to a group of kidney disorders characterized by inflammatory injury in the glomerulus. The child with acute glomerulonephritis will have an excessive accumulation of water and retention of sodium, leading to circulatory congestion and edema. Excessive fluid volume would be a focus for this disease process. No risk for infection is associated with this disease; it is a postinfectious process, usually from a pneumococcal, streptococcal, or viral infection. Hematuria is present, but the loss of blood is not enough to constitute a risk for injury. The disease is acute as opposed to chronic, and almost all children recover completely.
2、A child with laryngotracheobronchitis (croup) is placed in a cool mist tent. The mother becomes concerned because the child is frightened, consistently crying and trying to climb out of the tent. Which is the most appropriate nursing action?
1.Tell the mother that the child must stay in the tent.
2.Place a toy in the tent to make the child feel more comfortable.
3.Call the health care provider and obtain a prescription for a mild sedative.
4.Let the mother hold the child and direct the cool mist over the child's face.
Correct Answer:4
Laryngotracheobronchitis (croup) is the inflammation of the larynx, trachea, and bronchi and is the most common type of croup. Cool mist therapy may be prescribed to liquefy secretions and to assist in breathing. If the use of a tent or hood is causing distress, treatment may be more effective if the child is held by the parent and a cool mist is directed toward the child's face (blow-by). A mild sedative would not be administered to the child. Crying would increase hypoxia and aggravate laryngospasm, which may cause airway obstruction. Options 1 and 2 would not alleviate the child's fear.
3、A 12-year-old girl is admitted to the hospital with suspected appendicitis. What nursing interventions should be implemented preoperatively?
1.Applying a heating pad for 5-minute intervals as prescribed
2.Administering acetaminophen (Tylenol) as needed for pain, as prescribed
3.Placing the adolescent in a fetal position, side-lying with legs drawn up to chest
4.Inserting a nasogastric tube and attaching it to low intermittent suction; measuring drainage as prescribed
Correct Answer:3
A client with appendicitis is more comfortable when lying in what is traditionally known as the fetal position, with the legs drawn up toward the chest. This flexed positioning assists in decreasing the pain that comes with appendicitis by decreasing the pressure on the abdominal area. Option 1 describes an intervention that is contraindicated because heat can lead to a ruptured appendix. Option 2 is incorrect. Pain medications are not given to the client with acute appendicitis because they may mask the symptoms that accompany a ruptured appendix. Option 4 describes a nursing intervention that may be necessary postoperatively.

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