The nurse is assessing a child with glomerulonephritis.
Which assessment finding requires follow-up by the nurse?
The nurse is assessing a child with glomerulonephritis.
Which assessment finding requires follow-up by the nurse?
A. periorbital edema
[21%]
B. decreased urine output
[15%]
C. headache rated 9/10 on the Numerical Rating Scale
[43%]
D. hematuria
[21%]
Statistics
Subject/Lesson
Subject
Child Health
Lesson
Urinary/Renal/Fluid and Electrolytes
Client Need
Test Plan
Reduction of Risk Potential
Related Topic
Potential for Complications from Surgical Procedures and Health Alterations
Item Type
Item Type
Knowledge/Comprehension
Explanation
Choice C is correct. A complication of glomerulonephritis is encephalopathy caused by severe hypertension associated with the disease process. A client's report of a severe headache (rated 9/10) should clue the nurse into checking the client's blood pressure. The client should be monitored for this potential complication, which can be avoided by closely monitoring the client's blood pressure.
Choice A is incorrect. Periorbital edema is an expected finding associated with glomerulonephritis. It is often most noticeable in the morning because the individual was lying supine while sleeping.
Choice B is incorrect. Decreased urine output is a manifestation associated with glomerulonephritis. This also places the client at risk for hypervolemia.
Choice D is incorrect. Hematuria, or blood in the urine, is a hallmark clinical feature of acute glomerulonephritis, especially post-streptococcal glomerulonephritis in children. The urine typically appears dark, tea-colored, cola-colored, or smoky, rather than bright red, due to the breakdown of red blood cells (RBCs) in the urinary tract.
Related Videos
2 Key Topics
Glomerulonephritis
21.4 Glomerular & Nephrotic Disorders
Additional Info
✓ AGN is a serious condition secondary to many infectious processes such as streptococcal infections, mononucleosis, and hepatitis.
✓ Nursing care aims to prevent the most common complications, including fluid volume overload and hepatic encephalopathy.
✓ The client may have dietary restrictions such as fluid, sodium, and potassium.
✓ Daily weights are necessary to determine the client's volume status and should be obtained in the morning after the first void using the same scale while the client is wearing the same clothing.
✓ Daily weights are more reliable for determining fluid volume status than intake and output.
