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, frequent nosebleeds, 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, upper extremity hypotension, 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, increased intracranial pressure, 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. The nurse should determine if the client’s health care surrogate is aware of the risks and benefits of the procedure. A health care surrogate is a person who is authorized to make health care decisions for a client who is unable to do so. The nurse has a legal and ethical responsibility to ensure that the client’s surrogate has given informed consent for the surgery, which means that they have received adequate information about the procedure, its purpose, its risks, its benefits, and its alternatives.
Choice A is wrong because sending the unsigned informed consent form to the facility’s risk manager does not ensure that the client’s surrogate has given informed consent. The risk manager is not involved in the consent process and cannot authorize the surgery without the surrogate’s consent.
Choice B is wrong because ensuring that the client’s family supports the provider’s decision for surgery is not the same as obtaining informed consent from the surrogate.
The family may have different opinions or preferences than the surrogate, and the surrogate may not agree with the provider’s decision. The nurse should respect the surrogate’s autonomy and authority to make decisions for the client.
Choice C is wrong because determining if the procedure is medically necessary for the client is not the nurse’s role.
The provider is responsible for determining the medical necessity of the surgery and explaining it to the surrogate. The nurse should not question or interfere with the provider’s judgment unless there is evidence of negligence or malpractice.
Correct Answer is A
Explanation
Answer and explanation.
The correct answer is choice A. A nontender, protruding abdomen is a normal finding for a 2year-old toddler. This is due to the immature development of the abdominal muscles and the relatively large size of the liver and kidneys in relation to the rest of the body.
Choice B is wrong because the head circumference should be equal to or less than the chest circumference by age 2. A head circumference that exceeds the chest circumference could indicate hydrocephalus or other neurological problems.
Choice C is wrong because the fontanels, or soft spots on the skull, should be closed by age 18 months. Palpable fontanels could indicate dehydration, malnutrition, or congenital disorders.
Choice D is wrong because the natural loss of deciduous teeth, or baby teeth, usually begins around age 6. Premature loss of teeth could indicate dental caries, trauma, or endocrine disorders.
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