A nurse is assessing a 7-year-old who has been diagnosed with acute pyelonephritis, what assessment finding requires immediate action by the nurse?
Blood pressure of 136/92 mg
Heart rate of 100 bpm
Decreased urine output
Tea-colored urine
The Correct Answer is A
Rationale:
A. Hypertension (blood pressure of 136/92 mm Hg) in a child with acute pyelonephritis can indicate a severe condition that may lead to renal damage or worsening kidney function. Immediate intervention is necessary to manage high blood pressure and prevent complications.
B. A heart rate of 100 bpm is within normal limits for a 7-year-old and does not require immediate action.
C. Decreased urine output is concerning and needs monitoring, but hypertension is the more urgent issue.
D. Tea-colored urine suggests hematuria or concentrated urine, which is important but not as immediately life-threatening as high blood pressure.
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Correct Answer is C
Explanation
Rationale:
A. A capillary refill greater than 3 seconds suggests ongoing dehydration and poor perfusion, indicating that oral rehydration has not been fully effective.
B. A respiratory rate of 24/min is within normal limits for a 4-year-old but is not a direct indicator of hydration status.
C. A urine specific gravity of 1.015 is within the normal range, indicating adequate hydration and that oral rehydration therapy has been effective.
D. A heart rate of 130 bpm, while potentially normal for a 4-year-old, does not specifically indicate the effectiveness of rehydration therapy.
Correct Answer is C
Explanation
Rationale:
A. Decreased urine specific gravity is not typical; rather, increased specific gravity may be noted due to concentrated urine.
B. Hypotension is not usually associated with acute glomerulonephritis; hypertension is more common due to fluid retention and renal impairment.
C. A positive antistreptolysin O titer indicates a recent streptococcal infection, which is often the cause of post-streptococcal glomerulonephritis.
D. Elevated blood urea nitrogen (BUN) and creatinine levels are expected due to impaired kidney function, not low levels.