A school-aged client admitted to the hospital because of decreased urine output and periorbital edema is diagnosed with glomerulonephritis. Which of the following interventions should receive the highest priority?

Correct Answer: C

Rationale: The correct answer is C: Obtaining daily weight measurements. Daily weight measurements are crucial in monitoring fluid status in clients with glomerulonephritis, as sudden weight gain can indicate fluid retention and worsening of the condition. This intervention allows for early detection of fluid imbalances, guiding appropriate fluid management and treatment adjustments. Assessing vital signs every four hours (choice A) is important but not the highest priority in this scenario, as monitoring weight is more specific for fluid status changes. Monitoring intake and output every 12 hours (choice B) is also important, but not as immediate as obtaining daily weight measurements. Obtaining serum electrolyte levels daily (choice D) is essential, but weight measurements take precedence in assessing fluid status.

Correct Answer: A

Rationale: The correct answer is A: Intubation setup. In a newborn with a diaphragmatic hernia, there is a risk of respiratory distress due to lung compression. Intubation may be necessary to assist with breathing. The nurse should ensure the intubation setup is prepared to provide immediate respiratory support if needed. Choice B (Appropriate bag and mask) may be used for initial respiratory support but intubation provides more secure airway management. Choice C (Sterile gauze and saline) is not directly related to managing a diaphragmatic hernia. Choice D (Soft arm restraints) is not necessary for this specific situation.

Correct Answer: C

Rationale: Step 1: Whole milk is high in saturated fat and calories, contributing to excessive weight gain. Switching to 2 percent milk reduces fat intake. Step 2: Decreasing milk consumption and limiting fruit juice helps balance calorie intake and encourages the child to eat solid foods. Step 3: Offering water in between meals ensures hydration without additional calories. Step 4: Adjusting the child's diet in this manner promotes healthier eating habits and can help normalize weight-to-height percentile. In summary, option C is correct as it addresses the concerns of excessive milk and juice consumption while promoting a balanced diet. Options A, B, and D are incorrect because eliminating fruit juice alone may not address the overall calorie intake issue. Healthy snacks and creative presentation may not address the specific problem of excessive milk consumption. Increasing exercise alone may not directly impact the child's diet and weight-to-height percentile.

Correct Answer: C

Rationale: The primary purpose of a transitional object is to decrease anxiety in the toddler. The object provides comfort and security when the child is separated from their caregiver, reducing feelings of distress. It serves as a source of emotional support and helps the child manage their emotions independently. The other choices are incorrect because they focus on the parent's feelings (A), behavior modification (D), or simply keeping the child quiet (B), rather than addressing the emotional needs of the child.

Correct Answer: C

Rationale: The correct answer is C: Conjunctival hyperemia. In Kawasaki disease, conjunctival hyperemia is a common clinical manifestation during the acute stage due to the inflammation of blood vessels. This is typically seen as redness in the eyes. Cracked lips (A) are more characteristic of conditions like dry weather or vitamin deficiencies. A normal appearance (B) would not be expected in a child with acute Kawasaki disease as they typically exhibit symptoms. Desquamation of the skin (D) is more commonly seen in the subacute stage of the disease rather than the acute stage.