A nurse in an emergency department is assessing an adolescent who reports inhalation of gasoline.
Which of the following findings should the nurse expect?
Ataxia.
Hypothermia.
Hyperactive reflexes.
Pinpoint pupils.
The Correct Answer is A
Ataxia is a neurological sign that refers to a lack of muscle coordination and can cause staggering. Inhalation of gasoline vapors can cause symptoms such as dizziness or lightheadedness, headache, facial flushing, coughing or wheezing, staggering, slurred speech, blurry vision and weakness.
Choice B is wrong because Hypothermia is not an answer because hypothermia refers to a dangerously low body temperature and is not a symptom of gasoline inhalation.
Choice C is wrong because Hyperactive reflexes are not an answer because hyperactive reflexes refer to overactive or overresponsive reflexes and are not a symptom of gasoline inhalation.
Choice D is wrong because Pinpoint pupils are not an answer because pinpoint pupils refer to abnormally small pupils and are not a symptom of gasoline inhalation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
This is because oxygen saturation below 90% indicates that the infant is not getting enough oxygen and central cyanosis (bluish color of the skin due to lack of oxygen) is a sign of severe respiratory distress.
Both of these findings require immediate medical attention.
Choice A is wrong because cough or difficulty in breathing, while concerning, may not require immediate reporting to the provider as they are common symptoms of RSV infection.
Choice C is wrong because severe respiratory distress (e.g grunting, very severe chest indrawing), while concerning, may not require immediate reporting to the provider as they are common symptoms of RSV infection.
Choice D is wrong because signs of pneumonia with a general danger, while concerning, may not require immediate reporting to the provider as they are common symptoms of RSV infection.
Correct Answer is A
Explanation
According to the normal pediatric vital signs chart provided by Cleveland Clinic, the normal blood pressure range for a 2-year-old child should be between 90- 105/55-70 mm Hg. The blood pressure of 118/74 mm Hg is higher than the normal range for a 2- year-old child and should be reported to the provider.
Choice B is wrong because a respiratory rate of 26/min falls within the normal range of 20-30 breaths per minute for a child between ages 1 and.
Choice C is wrong because a pulse rate of 98/min falls within the normal range of 80-125 beats per minute for a child between ages 1 and.
Choice D is wrong because a temperature of 37.2° C (99° F) falls within the normal range for children which is around 98.6 degrees.
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