12-year-old Caroline has recurring nephrotic syndrome; which of the following areas of potential disturbances should be a prime consideration when planning ongoing nursing care?

Correct Answer: A

Rationale: For 12-year-old Caroline with recurring nephrotic syndrome, body image should be a prime consideration when planning ongoing nursing care. Nephrotic syndrome can cause physical changes such as weight gain, swelling, and changes in appearance due to the disease process and treatment side effects like corticosteroids. These physical changes can impact a child's self-esteem and body image, especially during the sensitive pre-adolescent period. As a result, addressing Caroline's body image concerns through open communication, providing support, promoting self-acceptance, and involving her in decision-making regarding her care can significantly impact her emotional well-being and overall quality of life.

Correct Answer: C

Rationale: Encouraging the breastfeeding mother to adhere to a low-phenylalanine diet is an important nursing consideration in the care of the newborn with PKU. Phenylketonuria (PKU) is an inborn error of metabolism in which the body cannot metabolize phenylalanine properly. If a newborn with PKU consumes formula or breast milk that contains high levels of phenylalanine, it can lead to severe intellectual disability and other health complications. By encouraging the breastfeeding mother to follow a low-phenylalanine diet, the newborn's exposure to phenylalanine can be minimized, helping to prevent the negative effects of PKU.

Correct Answer: D

Rationale: Too rapid infusion of hyperalimentation solutions can lead to circulatory overload due to the rapid volume expansion, which can strain the heart and lead to fluid overload. This can manifest as symptoms such as shortness of breath, crackles in the lungs, and edema. Additionally, a rapid infusion rate can cause a sudden surge in glucose levels, potentially leading to hypoglycemia due to increased insulin release in response to the elevated glucose levels. It is important for the nurse to maintain a careful and appropriate infusion rate to prevent these complications and ensure patient safety.

Correct Answer: B

Rationale: When assessing a client with an autoimmune disorder, the nurse should look for signs such as hives or rashes. Autoimmune disorders can manifest with various skin manifestations, including hives or rashes, which may be indicative of an autoimmune response. These skin manifestations may occur due to the immune system mistakenly attacking the body's own tissues. Observing and monitoring these skin changes can help in assessing and managing the autoimmune disorder in the client. Additionally, localized inflammation may also be present in autoimmune disorders, but hives or rashes are more commonly associated with these conditions.

Correct Answer: D

Rationale: Involvement of two lymph node regions above the diaphragm with systemic symptoms corresponds to stage IIB.