Nokea
The nurse is assessing an infant with aortic stenosis and identifies bilateral fine crackles in both lung fields. Which additional finding should the nurse expect to obtain?
- A. Hemiplegia.
- B. Fever.
- C. Vigorous feeding and satiation.
- D. Hypotension and tachycardia.
Correct Answer: D
Rationale: Aortic stenosis can lead to heart failure and pulmonary edema, causing bilateral fine crackles, with hypotension and tachycardia as additional signs of decreased cardiac output.
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An adolescent client reports to the nurse of walking with a limp due to pain localized in the right knee which worsens at night but denies any recent injury or trauma. The nurse observes swelling and tenderness in the right lower thigh, and imaging results reveal radial ossification in the soft tissues. Which condition should the nurse consider as the probable cause of the findings?
- A. Osteosarcoma
- B. Growing pains
- C. Rhabdomyolysis
- D. Hemosiderosis
Correct Answer: A
Rationale: Pain, swelling, tenderness, and radial ossification suggest osteosarcoma, a common bone tumor in adolescents, unlike the other conditions.
The nurse is assessing the growth and development of a 3-year-old child. Which speech and language skills should the nurse identify as normal developmental milestones for this child?
- A. Speaks in simple sentences with four or more words.
- B. Recognizes most letters and numbers.
- C. Uses gestures with 1-to-2-word sentences.
- D. Uses 1-word sentences.
Correct Answer: A
Rationale: Speaking in simple sentences with four or more words is a normal milestone for a 3-year-old.
The nurse is caring for an infant who was recently diagnosed with a congenital heart defect. Which assessment finding is most important for the nurse to report to the healthcare provider?
- A. Audible heart murmur.
- B. Heart rate of 162 beats/minute.
- C. Poor oral intake and suckling effort.
- D. Weight gain of 2.2 lbs. (1 kg) in the last 48 hours.
Correct Answer: C
Rationale: Poor oral intake and suckling effort indicate feeding difficulties, which can lead to dehydration and poor weight gain, requiring immediate reporting.
While obtaining the vital signs of a 10-year-old child who had a tonsillectomy this morning, the nurse observes the child swallowing every 2 to 3 minutes. Which assessment should the nurse implement?
- A. Inspect the posterior oropharynx.
- B. Touch the tonsillar pillars to stimulate the gag reflex.
- C. Ask the child to speak to evaluate change in voice tone.
- D. Assess for teeth clenching or grinding.
Correct Answer: A
Rationale: Frequent swallowing may indicate postoperative bleeding, so inspecting the oropharynx is critical.
The nurse is caring for a child with sickle cell disease who is experiencing a sickle cell crisis. Which finding should the nurse report to the healthcare provider immediately?
- A. Swelling in the hands or feet.
- B. Ulcers on the legs.
- C. Chest pain.
- D. Jaundice.
Correct Answer: C
Rationale: Chest pain may indicate acute chest syndrome, a life-threatening complication requiring immediate reporting.