A 4-year-old has acute glomerulonephritis and is admitted to the hospital. An appropriate nursing diagnosis for this child should be

Correct Answer: B

Rationale: The correct answer is B: Excess Fluid Volume Related to Decreased Plasma Filtration. In acute glomerulonephritis, the glomeruli are inflamed, leading to decreased filtration of plasma and retention of fluid. This results in excess fluid volume. This nursing diagnosis addresses the specific physiological issue of fluid retention in this condition. A: Risk for Urinary Tract Injury is not directly related to acute glomerulonephritis but rather to other factors such as urinary obstruction or trauma. C: Risk for Infection is not the priority nursing diagnosis in acute glomerulonephritis. Hypertension is a common complication, but infection risk is not directly related to the condition. D: Disturbed Personal Identity is not a relevant nursing diagnosis in this case as it does not address the physiological issue of fluid volume excess.

Correct Answer: D

Rationale: The correct answer is D. Emesis after two feedings indicates that the infant is not tolerating the feedings well, which could be a sign of complications post-pyloromyotomy such as gastric outlet obstruction or poor stomach emptying. This warrants immediate attention to prevent further issues. A: Need for frequent burping is a common need for infants and does not necessarily indicate intolerance to feedings. B: Irritability during feeding could be due to various reasons such as hunger, discomfort, or gas, but it does not specifically indicate feeding intolerance. C: The passing of gas is a normal physiological process and does not directly indicate feeding intolerance. In summary, emesis after feedings is concerning as it suggests possible complications, while the other options are more commonly seen in infants and do not directly indicate feeding intolerance.

Correct Answer: A

Rationale: The correct answer is A: Delay supplemental foods until the infant is 4 to 6 months old. This instruction aligns with the current recommendations from major health organizations like the American Academy of Pediatrics. Introducing solid foods too early can increase the risk of allergies, obesity, and other health issues. Delaying until 4 to 6 months allows the infant's digestive system to mature, reducing the likelihood of food allergies and digestive problems. Choice B is incorrect because weight alone is not a reliable indicator of an infant's readiness for solid foods. Choice C is incorrect as introducing diluted fruit juice at 2 months can be harmful due to the sugar content and lack of essential nutrients. Choice D is incorrect as adding rice cereal to address sleep issues is not recommended and may increase the risk of choking or overfeeding.

Correct Answer: A

Rationale: The correct answer is A: A push-and-pull toy. At 18-24 months, children are developing gross motor skills. Push-and-pull toys help strengthen muscles and improve coordination. They also encourage balance and enhance spatial awareness. Nesting blocks are more suitable for fine motor skills, while a bicycle with training wheels requires more advanced motor skills. A computer is not developmentally appropriate as young children need hands-on, physical play for optimal growth and learning.

Correct Answer: B

Rationale: The correct answer is B: Peripheral hypoxia. Clubbing of fingers is commonly seen in conditions with chronic hypoxia, such as tetralogy of Fallot. The lack of oxygen in the blood causes changes in the blood vessels leading to clubbing. Anemia (choice A) may cause tissue hypoxia but is not directly related to clubbing. Delayed physical growth (choice C) is not a known cause of clubbing. Destruction of bone marrow (choice D) is unrelated to clubbing.