A nurse on a pediatric unit is caring for a 5-week-old infant.
Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again.
Nurses' Notes
2000:
Infant awake and alert in parent's arms in bedside chair. Trunk, arms, and hands warm to palpation. Edema noted to hands, feet, and periorbital area. Weak bilateral femoral pulses. Lower extremities cool to palpation. Lungs clear bilaterally on auscultation. Mucous membranes pink and moist.
2200:
Infant asleep in crib. Heart rate regular, no murmur on auscultation.
Vital Signs
2000:
Blood pressure 98/60 mm Hg right arm: 60/40 mm Hg right leg Heart rate 168/min
Respiratory rate 34/min
Temperature 37° C (98.6° F)
Oxygen saturation 97% on room air, right wrist
Trunk, arms, and hands warm to palpation
Edema noted to hands, feet, and periorbital area
Weak bilateral femoral pulses
Lower extremities cool to palpation
Mucous membranes pink and moist
Blood pressure 98/60 mm Hg right arm: 60/40 mm Hg right leg Heart rate 168/min
Respiratory rate 34/min
The Correct Answer is ["B","C","D","F"]
Findings that require follow-up:
- Edema noted to hands, feet, and periorbital area: Edema in these areas, especially periorbital edema, could indicate fluid retention, possibly from heart failure, kidney issues, or circulatory problems. This should be further evaluated to determine the underlying cause.
- Weak bilateral femoral pulses: Weak femoral pulses could suggest a circulatory problem or arterial insufficiency. This is concerning as it could indicate a vascular or cardiac issue that requires immediate investigation.
- Lower extremities cool to palpation: Cool lower extremities may indicate poor circulation, which can be caused by a cardiovascular issue, such as shock or impaired circulation, which needs immediate attention.
- Blood pressure discrepancy (right arm: 98/60 mm Hg, right leg: 60/40 mm Hg): A significant difference in blood pressure readings between the arms and legs (known as a differential blood pressure) can indicate conditions like coarctation of the aorta (a congenital heart defect), which requires immediate follow-up.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "I will set the temperature of the hot water heater to 140 degrees." The hot water heater should be set to 120°F (49°C) or lower to prevent scald injuries. A setting of 140°F significantly increases the risk of burns.
B. "I will turn pot handles towards the front of the stove when cooking." Pot handles should be turned toward the back of the stove to prevent a child from grabbing or knocking them over.
C. "I don't need to apply sunscreen to my child if he is outside after 3 p.m." Sunscreen is essential any time a child is outdoors during daylight, regardless of the time, to protect against harmful UV rays.
D. "I will plug protective guards into my electrical outlets." Installing protective guards helps prevent electrical burns by stopping toddlers from inserting objects into outlets.
Correct Answer is A
Explanation
A. A 15-year-old client who requires an open reduction of a fracture. Minors generally require parental or guardian consent for surgical procedures unless emancipated.
B. While an infant cannot consent, IV antibiotics are considered a routine medical treatment. General consent for treatment is usually signed upon admission to the hospital, which covers standard nursing interventions like starting an IV or administering prescribed medications. Specific informed consent forms are typically reserved for higher-risk procedures (surgeries, blood transfusions, etc.).
C. In most jurisdictions, minors can provide their own consent for medically emancipatedconditions. These typically include prenatal care, contraception, testing and treatment for STIs, and substance abuse treatment. The nurse would not need to obtain consent from a guardian in this specific context to protect the minor's privacy and access to care.
D. A chest x-ray is a non-invasive diagnostic procedure. Similar to the administration of medications, these are covered under the general consent for treatment signed at the time of admission. They do not require a separate, formal informed consent document for each individual imaging study.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.