When caring for a client with nephrotic syndrome, which assessment is most important for the nurse to obtain?

Correct Answer: A

Rationale: In caring for a client with nephrotic syndrome, obtaining a daily weight is the most important assessment for the nurse to perform. Nephrotic syndrome is characterized by massive protein loss leading to edema, particularly in the abdominal area. Daily weight monitoring is crucial as it reflects fluid retention or loss, which can indicate disease progression or response to treatment. Changes in weight help guide medication dosages, fluid restriction, and dietary adjustments. Vital signs are important in assessing overall health but may not provide specific information related to fluid status in nephrotic syndrome. Level of consciousness is more relevant in neurological conditions, not directly related to nephrotic syndrome. Bowel sounds are not the priority in this case unless there are specific gastrointestinal symptoms present, which are not typically associated with nephrotic syndrome. Educationally, understanding the rationale behind the importance of daily weight monitoring in nephrotic syndrome highlights the link between pathophysiology and nursing assessment. It reinforces the significance of regular assessments in providing optimal care for pediatric patients with complex conditions.

Correct Answer: D

Rationale: In the context of a client with carpal tunnel syndrome experiencing pain as a collaborative problem, the correct etiology is identified as "Compression of a nerve" (Option D). Carpal tunnel syndrome involves the compression of the median nerve as it passes through the carpal tunnel in the wrist. This compression leads to symptoms such as pain, numbness, and tingling in the affected hand and fingers. Explanation of why the other options are incorrect: A) Irritation of nerve endings: While irritation of nerve endings can contribute to pain, in carpal tunnel syndrome, the primary issue is nerve compression rather than just irritation. B) Diminished blood flow: Diminished blood flow may lead to tissue ischemia but is not the primary cause of pain in carpal tunnel syndrome. C) Ischemic tissue changes: Ischemic tissue changes may occur if there is prolonged compression leading to nerve damage, but this is not the immediate etiology of pain in carpal tunnel syndrome. Educational context: Understanding the etiology of pain in carpal tunnel syndrome is crucial for nurses caring for pediatric clients with this condition. By recognizing that pain arises from nerve compression within the carpal tunnel, nurses can implement appropriate interventions to alleviate pain, such as splinting, ergonomic modifications, and possibly surgical intervention in severe cases. Educating patients and families about the importance of managing this compression can help improve outcomes and quality of life for pediatric clients with carpal tunnel syndrome.

Correct Answer: C

Rationale: In this scenario, the correct intervention for the nurse to implement is option C, which is to palpate the bladder above the symphysis pubis. This is the correct choice because the client is exhibiting symptoms of urinary retention, such as difficulty starting the stream, frequent urination, and sensation of incomplete emptying. Palpating the bladder can help the nurse assess for bladder distension, which could indicate urinary retention. Option A, collecting a urine specimen for culture analysis, is incorrect in this situation because the client's symptoms are more indicative of a mechanical issue (urinary retention) rather than an infection. Therefore, a urine culture may not provide relevant information at this point. Option B, reviewing the client's fluid intake prior to bedtime, is also not the most appropriate choice as it does not address the immediate concern of urinary retention that the client is experiencing. While managing fluid intake is important for overall urinary health, it is not the priority intervention in this case. Option D, obtaining a fingerstick blood glucose level, is unrelated to the client's current presentation of urinary retention symptoms. This option would be more relevant if the client had symptoms suggestive of diabetes or if the nurse suspected hyperglycemia as a potential cause of the urinary issues, which is not the case here. In an educational context, understanding how to assess and address urinary retention in patients is crucial for nurses, especially when caring for older adult clients who may be more prone to this issue. Palpating the bladder is a fundamental skill that helps nurses gather important data to guide further interventions or referrals for appropriate management.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) Decreased frequency of episodes of VT. Lidocaine is a class Ib antiarrhythmic medication that works by stabilizing the neuronal membrane and decreasing automaticity in the ventricles. It is commonly used to treat ventricular arrhythmias like ventricular tachycardia (VT). Therefore, a therapeutic response to lidocaine would be a reduction in the frequency or cessation of VT episodes, indicating that the medication is effectively managing the arrhythmia. Option A) Stabilization of blood pressure ranges may not be directly related to the therapeutic response of lidocaine for VT. Lidocaine primarily targets cardiac arrhythmias, and its impact on blood pressure may be secondary or indirect. Option B) Cessation of chest pain is not a typical response to lidocaine infusion for VT. While chest pain may be associated with myocardial infarction, lidocaine's primary action is on cardiac arrhythmias, not pain relief. Option C) Reducing heart rate is not the primary goal of using lidocaine for VT. The focus is on restoring normal cardiac rhythm and preventing life-threatening arrhythmias, rather than specifically targeting heart rate reduction. In an educational context, understanding the mechanism of action and therapeutic indications of antiarrhythmic medications like lidocaine is crucial for nurses caring for patients with cardiovascular conditions. By grasping the specific responses expected from these medications, nurses can effectively monitor and evaluate the effectiveness of treatment interventions, ensuring optimal patient outcomes.

Correct Answer: D

Rationale: The correct answer is D) Elevate head of bed 60 to 90 degrees. This position facilitates proper tube placement by utilizing gravity to assist in guiding the nasogastric tube into the stomach. Elevating the head of the bed also helps prevent aspiration and ensures proper positioning of the tube. Option A) Soaking the nasogastric tube in warm water is unnecessary and does not contribute to proper tube placement. Option B) Inserting the tube with the client's head tilted back can increase the risk of aspiration and is not the recommended technique for nasogastric tube insertion. Option C) Applying suction while inserting the tube is not appropriate as it can cause trauma to the nasal passages and increase the risk of incorrect tube placement. Educationally, understanding the rationale behind proper nasogastric tube placement is crucial for nurses caring for pediatric patients with gastrointestinal issues. By knowing the correct technique, nurses can ensure safe and effective interventions for their patients, preventing complications and promoting optimal outcomes.