A nurse is conducting discharge teaching to parents about the care of their infant after cardiac surgery. The nurse instructs the parents to notify the physician of what conditions occur. (Select all that apply.).
Respiratory rate of 36 breaths/minute at rest.
Appetite slowly increasing.
Temperature above 37.7° C (100° F).
New, frequent coughing.
Turning blue or bluer than normal.
Correct Answer : A,C,D,E
The correct answer is choices A, C, D, and E.
Choice A rationale:
A respiratory rate of 36 breaths/minute at rest is concerning in a pediatric client, as it may indicate respiratory distress or an underlying respiratory condition.
Choice B rationale:
An increasing appetite is generally a positive sign and not typically concerning unless accompanied by other symptoms.
Choice C rationale:
A temperature above 37.7° C (100° F) is concerning as it indicates fever, which could be a sign of infection or other medical conditions.
Choice D rationale:
New, frequent coughing is concerning as it may indicate respiratory infections, asthma, or other respiratory issues.
Choice E rationale:
Turning blue or bluer than normal (cyanosis) is a serious symptom indicating inadequate oxygenation and requires immediate medical attention.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Ribbon-like stools are not characteristic of intussusception. Intussusception is a medical emergency where one portion of the intestine invaginates or telescopes into another. This condition can lead to intestinal obstruction and compromised blood flow, causing severe abdominal pain, vomiting, and bloody stools. The characteristic stool appearance associated with intussusception is "currant jelly" stools. These stools contain mucus, blood, and sloughed mucosal tissue, giving them a characteristic dark, sticky, and jelly-like appearance. This occurs due to the mixture of blood and mucus within the intestines.
Choice B rationale:
Hard stools positive for guaiac indicate the presence of occult blood in the stool, but this finding is not specific to intussusception. Occult blood in the stool can be a sign of gastrointestinal bleeding from various causes, such as ulcers, gastritis, or colorectal polyps. It is not a characteristic feature of intussusception.
Choice D rationale:
Loose, foul-smelling stools are nonspecific and can occur due to various gastrointestinal disorders, dietary issues, or infections. This description does not specifically indicate intussusception.
Correct Answer is C
Explanation
Choice A rationale:
Signs of stress can indeed manifest in various ways, including stomach pains and changes in behavior. However, in this scenario, the child's symptoms of stomach pains, aggression, and stubbornness might indicate a physical problem causing emotional stress. It's essential to consider other possibilities before attributing the symptoms solely to stress.
Choice B rationale:
Developmental delay could be a potential cause of behavioral issues in a child, but it doesn't explain the stomach pains. Moreover, a developmental delay would typically have been identified earlier in the child's life through regular screenings and assessments.
Choice C rationale:
A physical problem causing emotional stress, such as an undiagnosed medical condition, can lead to both stomach pains and behavioral changes. Considering this possibility is crucial in this situation. It's essential to conduct a thorough physical examination and medical evaluation to rule out any underlying health issues.
Choice D rationale:
Lack of adjustment to the school environment could contribute to behavioral problems in a child. However, it's essential to first investigate the physical symptoms, like stomach pains, before solely attributing the behavior to school adjustment issues. Physical health should be thoroughly assessed to rule out any medical causes for the symptoms.
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