The nurse is conducting an admission assessment on a school-age child with acute renal failure. Which are the primary clinical manifestations the nurse expects to find with this condition?

Correct Answer: A

Rationale: Acute renal failure is characterized by a sudden decrease in kidney function, resulting in the reduced ability to excrete waste products and maintain fluid balance. The primary clinical manifestations typically seen in acute renal failure include oliguria (low urine output) due to decreased kidney function, and hypertension (high blood pressure) as the body retains excess fluid and waste products. These symptoms indicate impaired kidney function and the need for immediate medical intervention to prevent further complications. Hematuria, proteinuria, muscle cramps, bacteriuria, and facial edema are not typically primary clinical manifestations of acute renal failure.

Correct Answer: C

Rationale: In an infant with complete transposition of the great vessels, the survival at birth depends on the presence of a patent ductus arteriosus (PDA) to allow mixing of oxygenated and deoxygenated blood. In this condition, the aorta arises from the right ventricle and the pulmonary artery arises from the left ventricle, leading to separate circulatory pathways for oxygenated and deoxygenated blood. The survival of the infant is dependent on the remaining fetal shunts, such as a PDA, to maintain an adequate mixing of blood until corrective surgery can be performed. Therefore, the presence of a PDA is essential for the survival of an infant with complete transposition of the great vessels at birth.

Correct Answer: D

Rationale: In stable asthmatic patients, additional interventions like systemic steroids or increased beta-agonist doses are not always necessary unless there are signs of exacerbation.

Correct Answer: B

Rationale: Hypospadias is a congenital condition where the opening of the urethra is located on the underside of the penis instead of the tip. If a child is born with hypospadias, circumcision should be avoided. Circumcision involves removing part of the foreskin, which can cause complications for children with hypospadias, such as affecting future surgical repair procedures or worsening the hypospadias itself. Therefore, it is recommended to avoid circumcision in children with hypospadias.

Correct Answer: B

Rationale: Using pressure relieving devices when the client is in bed is essential to prevent skin breakdown. Clients with neuromuscular disorders are at higher risk for impaired skin integrity due to limited mobility and sensation. Pressure relieving devices such as specialized mattresses, cushions, or pads help distribute pressure evenly and reduce the risk of pressure ulcers. Maintaining good skin integrity is crucial in preventing complications and promoting the overall well-being of the client. It is important for the nurse to assess the client's risk factors, implement preventive measures like using pressure relieving devices, and monitor the client's skin regularly to prevent skin breakdown.