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A nurse is caring for a 10-year-old male child.

Exhibits

Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again.

Body system

Findings

Neurological

Generalized muscle weakness noted in bilateral lower extremities.

Child reports pain in legs on palpation, rates pain as 5 on a scale of 0 to 10.

Patellar deep tendon reflexes 1+ bilaterally.

Child is awake and alert, responds appropriately to questions.

Gastrointestinal

Abdomen slightly firm, bowel sounds hypoactive.

Reports last bowel movement was 3 days ago.

Generalized muscle weakness noted in bilateral lower extremities

Child reports pain in legs on palpation, rates pain as 5 on a scale of 0 to 10

Abdomen slightly firm, bowel sounds hypoactive

Reports last bowel movement was 3 days ago

Child is awake and alert, responds appropriately to questions

Answer and Explanation

The Correct Answer is ["A","B","C","D"]

Findings that require immediate follow-up:

Generalized muscle weakness noted in bilateral lower extremities: This could indicate a neurological or muscular issue, such as Guillain-Barré Syndrome (GBS), which is a concern after a viral infection or vaccination. This requires further investigation and close monitoring for any signs of progression, such as worsening weakness or respiratory involvement.
Child reports pain in legs on palpation, rates pain as 5 on a scale of 0 to 10: This pain could be indicative of muscle cramping or weakness, which may be associated with GBS or another neurological condition. Pain in combination with muscle weakness should be followed up closely.
Abdomen slightly firm, bowel sounds hypoactive, and reports last bowel movement was 3 days ago: This could suggest constipation or a gastrointestinal issue. However, the gastrointestinal symptoms may be secondary to the muscle weakness (if part of a systemic condition like GBS), and should be monitored, but it’s not as urgent as the neurological findings.

Findings that do not require immediate follow-up:

Patellar deep tendon reflexes 1+ bilaterally: A 1+ reflex is on the lower end of normal and does not indicate a severe problem by itself.
Child is awake and alert, responds appropriately to questions: This is a reassuring sign and does not require immediate follow-up.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is D

Explanation

A. "I will breathe in through the mouthpiece, hold my breath for 5 seconds, and then exhale.": Incorrect because the child should exhale forcefully and quickly into the device, not inhale or hold their breath.
B. "If I get a reading in the green zone, I will tell my parents right away so they can call the doctor.": Incorrect because a green zone reading indicates controlled asthma, and no immediate action is required.
C. "I will slowly exhale through the mouthpiece over a 10-second interval.": Incorrect because the exhalation should be rapid and forceful to measure peak flow effectively.
D. "I will record the highest reading of the three attempts." Recording the highest reading ensures accurate monitoring of airway status and helps the child track their progress over time.

A. Capillary refill greater than 4 seconds B. Bradycardia C. Tachypnea D. Lethargy

Correct Answer is C

Explanation

A. Capillary refill greater than 4 seconds: This indicates severe hypovolemia, not moderate.
B. Bradycardia: Bradycardia is uncommon in hypovolemia and may occur late as a sign of decompensation, especially in infants.
C. Tachypnea. Tachypnea is a compensatory response to hypovolemia as the body attempts to improve oxygenation and circulation.
D. Lethargy: While lethargy is a concerning sign, it is associated with more severe dehydration than moderate hypovolemia.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching an adolescent how to use a peak expiratory flow meter (PEFM). The nurse should identify that which of the following statements by the child indicates an understanding of the teaching?

Correct Answer is D

Explanation

A nurse is caring for a 6-month-old infant who has acute vomiting and diarrhea. Which of the following manifestations should the nurse identify as an indication of moderate hypovolemia?

Correct Answer is C

Explanation

A nurse is assessing a 4-month-old infant at a well-child visit. Which of the following findings should the nurse expect?

A nurse is planning care for an infant who has respiratory syncytial virus (RSV) and a respiratory rate of 46/min. Which of the following interventions should the nurse include in the plan of care?

A nurse is planning care for a child who is postoperative following a below-the-knee amputation. Which of the following interventions should the nurse include in the plan of care?

A nurse is providing discharge teaching to the parents of a school-age child who has epilepsy and a new prescription for phenytoin extended- release capsules. Which of the following instructions should the nurse include in the teaching?

A nurse on a pediatric unit is admitting a 5-year-old child who has a submersion injury and is awake and alert. The parent asks the nurse why the child needs to stay in the facility. Which of the following responses should the nurse make?

A charge nurse on a pediatric unit is reviewing informed consent guidelines with a newly licensed nurse. For which of the following clients should the nurse obtain informed consent from a guardian?

A nurse is performing an initial physical examination on a child. The nurse should recognize that which of the following manifestations indicates a possible brain tumor? Select all that apply.