A nurse is caring for an infant who has coarctation of the aorta.
Which of the following should the nurse identify as an expected finding?
Frequent nosebleeds.
Upper extremity hypotension.
Weak femoral pulses.
Increased intracranial pressure.
The Correct Answer is C

This is because coarctation of the aorta is a congenital condition where the aorta is narrow, usually in the area where the ductus arteriosus inserts. This causes a decrease in blood flow to the lower body, resulting in weak or absent pulses in the femoral arteries.
The other choices are incorrect for the following reasons:
Choice A is not a typical sign of coarctation of the aorta.
Nosebleeds can be caused by many factors, such as dry air, allergies, trauma, or bleeding disorders.
Choice B is also not a common finding in coarctation of the aorta. In fact, patients with this condition may have high blood pressure in the upper extremities due to the increased resistance of the narrowed aorta.
Choice D is not directly related to coarctation of the aorta.
Increased intracranial pressure can be caused by various conditions that affect the brain, such as head injury, stroke, infection, or tumor.
Normal ranges for blood pressure and pulse vary depending on age, sex, and health status. However, some general guidelines are:
- Blood pressure: less than 120/80 mmHg for adults; less than 95/65 mmHg for infants.
- Pulse: 60 to 100 beats per minute for adults; 100 to 160 beats per minute for infants.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice **D. Identify possible precipitating factors related to the infections**.
Choice D rationale:
As a charge nurse concerned about a recent increase in facility-acquired catheter infections, the first step should be to identify possible precipitating factors related to the infections. This involves conducting a thorough investigation to determine the root causes of the increased infection rates. By identifying the underlying factors, the nurse can then develop targeted interventions to address the specific issues and prevent further infections.
Choice A rationale:
While scheduling nursing staff training for infection control procedures is important, it should not be the first action taken. Before implementing training, it is crucial to identify the factors contributing to the increased infection rates to ensure that the training addresses the specific issues at hand.
Choice B rationale:
Meeting with providers to discuss measures to decrease the infections is a necessary step, but it should not be the first action. Providers need to be informed about the situation, but their input will be more valuable once the precipitating factors have been identified.
Choice C rationale:
Revising the current policy for catheter care may be necessary, but it should not be the first action. Policies should be based on evidence-based practices and tailored to address the specific issues identified through the investigation.
Correct Answer is B
Explanation
Previous violent behavior. According to the web search results, this is the best predictor of future violence among the given risk factors.
Other risk factors include past history of aggression, poor impulse control, and violence. Comorbidity that leads to acts of violence (psychotic delusions, command hallucinations, violent angry reactions with cognitive disorders).
Choice A is wrong because a history of being in prison is not a direct cause of violence, but rather a possible consequence of it.
Choice C is wrong because male gender is not a sufficient factor to predict violence, as there are many other variables involved.
Choice D is wrong because experiencing delusions is not necessarily associated with violence unless they are of a paranoid or persecutory nature.
Normal ranges for violence risk assessment are not standardized, but some tools that can be used include the Historical Clinical Risk Management-20 (HCR-20), the Violence Risk Appraisal Guide (VRAG), and the Psychopathy Checklist-Revised (PCL-R). These tools use different scales and criteria to evaluate the likelihood of violent behavior in individuals.
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