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: C

Rationale: Peripheral edema is a common clinical manifestation of systemic venous congestion that can occur with heart failure. In heart failure, the heart is unable to pump effectively, leading to a backup of blood in the veins. This increased pressure in the veins causes fluid to leak out into the surrounding tissues, resulting in swelling or edema, most commonly in the lower extremities. Tachypnea (rapid breathing) and tachycardia (fast heart rate) are more associated with the compensatory mechanisms of the body to try to maintain cardiac output and oxygenation. Pale, cool extremities are more indicative of poor peripheral perfusion, which can occur with severe heart failure but are not the typical manifestations of systemic venous congestion.

Correct Answer: D

Rationale: Rheumatic fever is an inflammatory disease that can develop after a streptococcal infection, such as strep throat. One of the most serious complications of rheumatic fever is cardiac involvement, specifically damage to the heart valves. This occurs due to the body's immune response attacking the heart valves as a result of molecular mimicry between streptococcal antigens and human tissues. The damage to the heart valves can result in conditions like mitral valve stenosis or regurgitation, which can lead to heart failure if not managed appropriately. Therefore, cardiac valve damage is a common and serious complication of rheumatic fever that requires monitoring and treatment to prevent long-term consequences.

Correct Answer: C

Rationale: The patient's symptoms of recent weight gain, 3+ pitting edema of his feet, distended neck veins, and crackles in his lungs are indicative of fluid volume excess. These signs and symptoms suggest that the patient is retaining too much fluid, leading to the edema and congestion in the lungs. The nursing diagnosis of Excess Fluid Volume is appropriate for this patient as it reflects the patient's current physiological state and guides the plan of care to address excess fluid accumulation through interventions such as diuretic therapy, fluid restriction, and monitoring of intake and output. Deficient fluid volume, Imbalanced nutrition more than body requirements, and Noncompliance are not appropriate nursing diagnoses given the patient's presentation of fluid overload.

Correct Answer: A

Rationale: During a uterosigmoidostomy procedure for treating a malignant tumor, a critical task of the nurse is to inspect for bleeding or cyanosis. Bleeding can be a potential complication during surgery and needs to be promptly identified and managed by the nurse. Cyanosis, which is a bluish discoloration of the skin due to lack of oxygen, can indicate a lack of blood flow to the tissues. Both bleeding and cyanosis are serious issues that require immediate attention to prevent further complications and ensure the client's safety and well-being. Therefore, assessing and monitoring for these signs are crucial tasks for the nurse in this situation.