Health Promotion and Maintenance
12. A nurse is caring for a child with acute glomerulonephritis. Which nursing assessment should be the nurse's first priority when caring for this child?
Health Promotion and Maintenance
12. A nurse is caring for a child with acute glomerulonephritis. Which nursing assessment should be the nurse's first priority when caring for this child?
. Obtaining a daily weight.
. Palpating extremities frequently for edema.
. Assessing urine for hematuria.
. Obtaining the child's blood pressure every shift.
Test-Taking Tip
Since glomerulonephritis involves improper kidney functioning, focus on responses dealing with fluid status. The best answer calls for monitoring complications of fluid imbalance with appropriate frequency.
Content Area: Child Health, Genitourinary; Integrated Process: Nursing Process, Assessment; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/System Specific Assessments
Health Promotion and Maintenance
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Answer 1 is correct because of primary concern in the child with glomerulonephritis is the monitoring of fluid balance. The nurse should obtain a weight for this child at the same time and on the same scale daily to monitor for changes. Answer 2 is incorrect because edema is expected in a child with glomerulonephritis and is part of the diagnostic assessment. Although the nurse should assess edema regularly, increased frequency of this assessment is not needed and is not the highest priority of care. Answer 3 is incorrect because gross hematuria is expected in a child with glomerulonephritis and is part of the diagnostic assessment. The presence of blood in the child's urine may last for some months; therefore, this is not the highest priority. Answer 4 is incorrect because a major complication of glomerulonephritis is hypertensive encephalopathy. The nurse should obtain blood pressure at least every 4 hours; once per shift is insufficient monitoring.