Nokea
An infant is suspected of having coarctation of the aorta. Which assessment finding is most related to coarctation of the aorta?
- A. Respirations are 70 per minute.
- B. Blood pressure is higher in the upper extremities than in the lower extremities.
- C. There is a heart murmur.
- D. Heart rate is 150 beats per minute.
Correct Answer: B
Rationale: Coarctation of the aorta causes aortic narrowing, leading to higher blood pressure in the upper extremities compared to the lower, a hallmark sign.
You may also like to solve these questions
A client with bipolar disorder is reluctant to take lithium (Lithane) as prescribed. The most therapeutic response by the nurse to his refusal is
- A. You need to take your medicine, this is how you get well.
- B. If you refuse your medicine, we'll just have to give you a shot.
- C. What is it about the medicine that you don't like?
- D. I can see that you are uncomfortable right now, I'll wait until tomorrow.
Correct Answer: C
Rationale: What is it about the medicine that you don't like? This fosters trust and open communication, encouraging the client to express concerns.
The nurse is caring for a client who has been placed on a hypothermia blanket. What should the nurse include in the care plan?
- A. Take frequent vital signs and perform frequent skin assessments
- B. Leave the hypothermia blanket on until the client's temperature reaches 98.6°F
- C. Place the client directly on the blanket
- D. Apply iced alcohol sponges to the part of the client's trunk not in contact with the blanket
Correct Answer: A
Rationale: Frequent vital signs monitor for hypothermia or cardiovascular instability, and skin assessments prevent pressure injuries or cold burns. Direct blanket contact, prolonged use, or alcohol sponges risk skin damage or ineffective cooling.
The nurse is caring for a client with a new colostomy. Which of the following client statements indicates a need for further teaching?
- A. I should change the pouch when it’s about one-third full.
- B. I should empty the pouch every morning.
- C. I should eat a high-fiber diet to prevent constipation.
- D. I should check the skin around the stoma for irritation.
Correct Answer: B
Rationale: Emptying the pouch every morning is a rigid schedule that does not account for individual bowel patterns; it should be emptied when one-third to one-half full. Options A, C, and D are correct: changing when one-third full prevents leaks, high-fiber diets promote regularity, and skin checks prevent breakdown.
The nurse assesses an 18-month-old child brought to the well child clinic for a routine check-up. Which finding would be of most concern to the nurse?
- A. The child can creep up stairs.
- B. The child is not toilet trained.
- C. The child drops objects handed to him.
- D. The child cries when his mother leaves him with a stranger.
Correct Answer: C
Rationale: Dropping objects handed to him suggests motor or neurological issues at 18 months, requiring evaluation. Creeping , not being toilet trained , and stranger anxiety are normal.
The LPN/LVN is caring for an adult who has pneumonia. The nurse should instruct the nursing assistant to report which information immediately?
- A. Restlessness
- B. Pink-colored skin
- C. Nonproductive cough
- D. Dry mouth
Correct Answer: A
Rationale: Restlessness may indicate hypoxia in pneumonia, a critical symptom requiring immediate reporting to assess oxygenation status.