The most appropriate nursing diagnosis for the child with acute ...

[luminitza]

The most appropriate nursing diagnosis for the child with acute glomerulonephritis is
 
  a. Risk for Injury related to malignant process and treatment
  b. Deficient Fluid Volume related to excessive losses
  c. Risk for Imbalanced Fluid Volume related to a decrease in plasma filtration
  d. Excess Fluid Volume related to fluid accumulation in tissues and third spaces

Question 2

Which action should the nurse working in the emergency department implement in order to decrease fear in a 2-year-old child?
 
  a. Keep the child physically restrained during nursing care.
  b. Allow the child to hold a favorite toy or blanket.
  c. Direct the parents to remain outside the treatment room.
  d. Let the child decide whether to sit up or lie down for procedures.

[Hikerman221]

Answer to Question 1

C
Feedback
A No malignant process is involved in acute glomerulonephritis.
B Excess fluid volume is found.
C Glomerulonephritis has a decreased filtration of plasma. The resulting decrease
in plasma filtration results in an excessive accumulation of water and sodium
that expands plasma and interstitial fluid volumes, leading to circulatory
congestion and edema.
D The fluid accumulation is secondary to the decreased plasma filtration.

Answer to Question 2

B
Feedback
A It may be necessary to restrain the toddler for some nursing care or procedures.
Because toddlers need autonomy and do not respond well to restrictions, the
nurse should remove any restriction or restraint as soon as safety permits.
B Allowing a child to hold a favorite toy or blanket is comforting.
C Parents should remain with the child as much as possible to calm and reassure
her.
D The toddler should not be given the overwhelming choice of deciding which
position she prefers.