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A nurse is assessing a 7-year-old who has been diagnosed with acute pyelonephritis, what assessment finding requires immediate action by the nurse?

A.

Blood pressure of 136/92 mg

B.

Heart rate of 100 bpm

C.

Decreased urine output

D.

Tea-colored urine

Answer and Explanation

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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View Related questions

Correct Answer is A

Explanation

Rationale:
A. Projectile vomiting is a classic sign of pyloric stenosis, where the thickened pylorus muscle obstructs the passage of food from the stomach to the small intestine, causing forceful vomiting.

B. Large amounts of bilious emesis would suggest an obstruction beyond the pylorus, which is not characteristic of pyloric stenosis.

C. Watery diarrhea is not associated with pyloric stenosis, which typically causes dehydration and constipation.

D. Steatorrhea, or fatty stools, is not a feature of pyloric stenosis but rather is associated with malabsorption syndromes.

Correct Answer is C

Explanation

Rationale:

A. A complete blood count is not specifically required before administering the rubella vaccine.

B. Lead screening is not related to rubella vaccination and is not required for this purpose.

C. The rubella vaccine is a live attenuated vaccine, and it is important to ensure that the patient is not pregnant because the vaccine could potentially harm the fetus. Therefore, a pregnancy test is a necessary precaution.

D. Tuberculosis screening is not related to the rubella vaccination and is not required for this purpose.

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