Try our free nursing testbanks today. click here to join
Teas 7 test, Hesi A2 and Nursing prep
Nursingprepexams LEARN. PREPARE. EXCEL!
  • Home
  • Nursing
  • TEAS
  • HESI
  • Blog
Start Studying Now

Take full exam for free

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.


Free Nursing Test Bank

  1. Free Pharmacology Quiz 1
  2. Free Medical-Surgical Quiz 2
  3. Free Fundamentals Quiz 3
  4. Free Maternal-Newborn Quiz 4
  5. Free Anatomy and Physiology Quiz 5
  6. Free Obstetrics and Pediatrics Quiz 6
  7. Free Fluid and Electrolytes Quiz 7
  8. Free Community Health Quiz 8
  9. Free Promoting Health across the Lifespan Quiz 9
  10. Free Multidimensional Care Quiz 10
Take full exam free

View Related questions

Correct Answer is B

Explanation

Rationale:

A. The Moro reflex, where the infant cries and extends both arms and legs in response to a loud noise, typically disappears by 4-6 months of age and would not be expected at 8 months.

B. The Babinski reflex, where the toes fan upward and out when the outer edge of the sole is stroked, is normal in infants and usually disappears by 12-24 months of age.

C. The tonic neck reflex (fencing reflex) typically disappears around 4-6 months of age, so it would not be expected in an 8-month-old.

D. The rooting reflex, where the infant turns their head toward the side of stimulation when the cheek is stroked, typically disappears by 3-4 months of age.

Correct Answer is D

Explanation

Rationale:

A. Tea-colored urine is more typical of glomerulonephritis rather than nephrotic syndrome.

B. A recent streptococcus infection is commonly associated with post-streptococcal glomerulonephritis, not nephrotic syndrome.

C. Polyuria is not a common feature of nephrotic syndrome; rather, oliguria (decreased urine output) may occur.

D. Periorbital edema is a hallmark sign of nephrotic syndrome, resulting from significant protein loss in the urine, leading to hypoalbuminemia and fluid retention.

Quick Links

Nursing Teas Hesi Blog

Resources

Nursing Test banks Teas Prep Hesi Prep Nursingprepexams Blogs
© Nursingprepexams.com @ 2019 -2026, All Right Reserved.