The nurse closely monitors the temperature of a child with minimal change nephrotic syndrome. The purpose of this assessment is to detect an early sign of which possible complication?

Correct Answer: A

Rationale: In a child with minimal change nephrotic syndrome, the nurse closely monitors the temperature to detect an early sign of infection. Children with nephrotic syndrome are more susceptible to infections due to loss of immunoglobulins in the urine, decreased serum complement levels, and altered immune function. Monitoring the temperature is important to identify any signs of infection early, as prompt treatment is crucial in preventing complications such as sepsis.

Correct Answer: B

Rationale: The best way to assess a patient's fatigue is to have her rate her fatigue on a scale of 0 to 10. Fatigue is primarily a subjective symptom, and patients are the best source of information regarding their own levels of fatigue. Using a standardized scale allows for a more quantitative assessment of the severity of the fatigue experienced by the patient. This can also help in monitoring changes in fatigue over time and evaluating the effectiveness of interventions aimed at managing fatigue. While observing the patient's activity level (choice A) can provide some information, it may not always accurately reflect the subjective experience of fatigue. Monitoring for changes in vital signs (choice C) and assessing hemoglobin and hematocrit values (choice D) can be important in evaluating overall health status and potential causes of fatigue, but they do not directly assess the patient's subjective experience of fatigue.

Correct Answer: C

Rationale: Diabetes insipidus is a condition characterized by excessive thirst and excretion of large amounts of dilute urine, resulting in fluid volume deficit. The posterior pituitary tumor in this case is likely causing decreased secretion of antidiuretic hormone (ADH), leading to the inability of the kidneys to concentrate urine and retain water. This imbalance results in the loss of fluid, leading to dehydration and electrolyte imbalances. Therefore, the most appropriate nursing diagnosis for this client is fluid volume deficit, as the priority is to address the dehydration and restore fluid balance to prevent further complications.

Correct Answer: B

Rationale: The first action the nurse should take upon the arrival of the adult who suffered a diving accident and is intubated and on a backboard with a cervical collar is to insert a large bore IV line. This is a priority because the person may require urgent fluid resuscitation or medication administration, and having IV access is crucial for immediate intervention in trauma cases. After establishing IV access, other assessments such as vital signs, lung sounds, and neurological checks can follow.

Correct Answer: C

Rationale: Swelling and discoloration after hydrocele repair are typically normal postoperative findings and do not require immediate intervention unless excessive or worsening.