A nurse is assessing a young child and suspects coarctation of the aorta based on which finding?
Hypotension
Unequal upper and lower extremity pulses
Excessive crying
Diastolic murmur
The Correct Answer is B
A. Hypotension is not typically associated with coarctation of the aorta; it more often leads to hypertension in the upper body.
B. Unequal pulses in the upper and lower extremities are a classic sign of coarctation of the aorta, as the obstruction typically affects blood flow to the lower body.
C. Excessive crying is not a specific indicator of coarctation of the aorta and can occur due to various reasons.
D. A diastolic murmur is not a primary indicator of coarctation of the aorta; it is more associated with other cardiac conditions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. The conjunctivae can show signs of cyanosis but is not the most reliable indicator of central cyanosis.
B. Ear lobes may show peripheral cyanosis but are not reliable for central cyanosis.
C. The soles of the feet are not typically assessed for cyanosis in this context.
D. The oral mucosa is the most reliable indicator of central cyanosis, as it reflects the oxygenation status of the blood more accurately.
Correct Answer is ["B","D","E","H"]
Explanation
A. While the child’s oral intake is reduced, it is not as immediately critical as the other findings. However, it should still be monitored and managed.
B. The child’s blood pressure has dropped to 88/48 mm Hg on Day 3, which is significantly lower than the initial value and may indicate hypotension. This could be a sign of worsening condition or dehydration and needs to be reported for further evaluation and intervention.
C. The temperature of 38.1° C (100.6° F) on Day 3 indicates a fever but is lower than the initial admission temperature. It is important but not as critical as the other findings in this scenario.
D. The oxygen saturation has decreased to 88% on room air, which is below the normal range and indicates hypoxemia. This is critical in a patient with pneumonia and cystic fibrosis, and it requires immediate attention to manage respiratory function and oxygenation.
E. The child has passed three large, frothy, foul-smelling stools, which could be indicative of a gastrointestinal complication, possibly related to cystic fibrosis. This change in bowel habits should be reported as it may impact the child’s overall condition and treatment plan.
F. The sputum is thick, yellow, and blood-streaked, which is consistent with the condition but does not require immediate reporting unless there is a significant change in color or consistency.
G. The reported pain level of 4 on a scale of 0 to 10 is moderate but not life-threatening. It should be managed, but it is less urgent compared to other assessment findings.
H. The child is using accessory muscles for respiration and is experiencing dyspnea while at rest, which suggests worsening respiratory distress. This is crucial to report as it reflects the severity of the pneumonia and may need adjustments in the treatment plan.
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