A nurse is assisting in the care of an adolescent in a pediatric clinic.
Click to highlight the findings the nurse should report to the provider. To deselect a finding, click on the finding again.
|
Body System |
Findings |
|
Cardiovascular |
Heart rhythm irregular. No murmurs noted. Blood pressure 80/50 mm Hg |
|
Gastrointestinal |
Abdomen soft and nontender to palpation. Hypoactive bowel sounds. |
|
Height/Weight |
Height 157.5 cm (62 in) Weight 39.9 kg (88 lb) BMI 16.1 (4th percentile) |
|
Behavioral |
Guardian states. "They have always been a good kid. They have never been in trouble or anything." Also reports exercising a lot and will run up and down the stairs when guardians are not home. |
Heart rhythm irregular.
No murmurs noted.
Blood pressure 80/50 mm Hg
Abdomen soft and nontender to palpation
Hypoactive bowel sounds
Weight 39.9 kg (88 lb)
BMI 16.1 (4th percentile)
Also reports exercising a lot and will run up and down the stairs when guardians are not home.
The Correct Answer is ["A","C","E","F","G","H"]
Rationale for correct choices:
• Heart rhythm irregular: Bradycardia and arrhythmias are common in adolescents with severe caloric restriction and low body weight. Reporting this finding is essential because cardiac complications are a leading cause of morbidity in anorexia nervosa.
• Blood pressure 80/50 mm Hg: Hypotension indicates cardiovascular compromise from malnutrition and fluid/electrolyte imbalance. Immediate provider awareness is needed to prevent syncope, shock, or other complications.
• Hypoactive bowel sounds: Reduced gastrointestinal motility is associated with prolonged starvation and electrolyte imbalances. Reporting this finding helps guide interventions for nutrition and gastrointestinal support.
• Weight 39.9 kg (88 lb): Significant weight loss over a short period and extremely low body weight indicates severe malnutrition. This is critical information for the provider for determining hospitalization or intensive intervention.
• BMI 16.1 (4th percentile): A BMI this low confirms severe underweight status and risk for multisystem complications. Reporting ensures the provider can prioritize medical and nutritional stabilization.
• Adolescent exercising excessively: Excessive exercise and caloric restriction are behaviors consistent with anorexia nervosa and increase risk for cardiac events, electrolyte imbalance, and musculoskeletal injury. Provider intervention is required for safety and treatment planning.
Rationale for incorrect choices:
• No murmurs noted: Absence of heart murmurs does not require reporting, as it is a normal finding and does not indicate acute risk.
• Abdomen soft and nontender to palpation: Normal abdominal assessment does not indicate acute concern. The priority is on hypoactive bowel sounds and associated gastrointestinal compromise.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. The client is admitted due to noncompliance at home: This statement is judgmental and assigns blame. Documentation should focus on observable behaviors and facts, not subjective opinions about the client’s actions.
B. The client uses neologisms when speaking to others: This entry describes a specific, observable behavior using objective clinical language. It accurately reflects the client’s communication patterns without bias or interpretation, aligning with proper documentation standards.
C. The client is disruptive and annoying to other clients in the facility: Terms like “disruptive” and “annoying” are subjective and judgmental. Documentation should describe the client’s behaviors factually, such as “client interrupted group activity by speaking loudly.”
D. The client's partner is making their symptoms worse: This statement is speculative and cannot be verified objectively. Accurate documentation should focus on observable behaviors and clinical findings rather than attributing causation without evidence.
Correct Answer is D
Explanation
A. "I should stop taking the medication if I get a headache.": Headaches are a common and expected side effect of sublingual nitroglycerin due to vasodilation. They do not require stopping the medication, though clients can use acetaminophen for relief if needed.
B. "I will swallow the tablet for faster absorption.": Sublingual nitroglycerin should be placed under the tongue for rapid absorption into the bloodstream. Swallowing the tablet delays onset of action and reduces effectiveness.
C. "I will wait 15 minutes before taking a second tablet.": The recommended interval between sublingual nitroglycerin doses is 5 minutes, up to a maximum of three doses in 15 minutes, with immediate medical attention if pain persists after the third dose.
D. "I should expect pain relief in 1 to 3 minutes.": Sublingual nitroglycerin acts rapidly, typically relieving anginal chest pain within 1 to 3 minutes. This demonstrates correct understanding of onset and proper use for acute episodes.
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