Exhibits
Click to mark whether the following are signs and symptoms of cerebral edema, respiratory distress, or both.
Course breath sounds
Decreased level of consciousness
Seizure activity
Irritability
Bradycardia
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A,B"},"E":{"answers":"B"}}
Course breath sounds - Respiratory Distress
Decreased level of consciousness - Cerebral Edema
Seizure activity - Cerebral Edema
Irritability - Both (Can be associated with both cerebral edema and respiratory distress)
Bradycardia - Cerebral Edema
Rationale:
Course breath sounds - Respiratory Distress
Course breath sounds could indicate the presence of secretions or fluid in the airways, which is a sign of respiratory distress. It suggests that there might be a problem with the airway or lung function.
Decreased level of consciousness - Cerebral Edema
A decreased level of consciousness can be a sign of cerebral edema, which is the swelling of the brain due to increased intracranial pressure. This can lead to changes in the child's mental status and responsiveness.
Seizure activity - Cerebral Edema
Seizure activity can be a manifestation of cerebral edema. Swelling and pressure in the brain can irritate brain tissue and lead to seizures.
Irritability - Both (Can be associated with both cerebral edema and respiratory distress) Irritability can be seen in both cerebral edema and respiratory distress. In cerebral edema, the pressure on the brain can cause discomfort and irritability. In respiratory distress, the child may be uncomfortable due to difficulty breathing.
Bradycardia - Cerebral Edema
Bradycardia (slow heart rate) can be associated with increased intracranial pressure and cerebral edema. It can be a response to the pressure on the brain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The ability to effectively communicate and provide accurate information can be impacted by external factors such as noise, distractions, or an unfamiliar environment. By assessing the surroundings, the nurse can identify and address any potential barriers to communication.
Once the nurse has addressed any environmental factors that may be hindering communication, they can proceed with other strategies to facilitate the health history assessment. This may include providing a printed healthcare assessment form to assist the client in organizing their thoughts or deferring the assessment until the client is less anxious.
Asking the family member to answer the questions should be considered if the client is unable to provide accurate information or is cognitively impaired. However, it is important to first address any environmental factors and attempt to engage the client directly in the assessment process.
Correct Answer is A
Explanation
The Ortolani maneuver is a physical examination technique used to assess for developmental dysplasia of the hip (DDH) in newborns. During the maneuver, the nurse gently abducts the infant's hips and applies gentle pressure to detect any instability or "click" at the hip joint. A positive Ortolani maneuver, where a click or clunk is felt or heard, can indicate the presence of a hip dislocation or dysplasia.
Asymmetrical buttocks can be a sign of hip dysplasia in newborns, and a positive Ortolani maneuver is an important finding that suggests a potential hip joint problem. Reporting this assessment test result to the healthcare provider allows for further evaluation and appropriate management of the newborn's hip condition.
The Plumb line test, which assesses fetal position curvature, is not directly related to hip dysplasia and may not be significant in this context.
The Babinski test, which reveals fanning out of the toes, is used to assess the integrity of the infant's neurological system and is not specific to hip dysplasia.
The Moro test, also known as the startle response, is a reflex assessment used to evaluate the newborn's neurological and sensory function. While it is important to assess the overall neurological status of the newborn, the Moro test is not specific to hip dysplasia.
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