A 3-year-old boy with a congenital heart defect is brought to the clinic by his mother because he has a fever and an earache. During the assessment, the mother asks the nurse why her child is at the 5th percentile for weight and height for his age. Which response is best for the nurse to provide?

"Does your child seem mentally slower than his peers also?"

"Haven't you been feeding him according to recommended daily allowances for children?"

"His smaller size is probably due to the heart disease."

"You should not worry about the growth tables. They are only averages for children."

Answer and Explanation

The Correct Answer is C

In this scenario, the child with a congenital heart defect is presenting with a fever and an

earache. The mother expresses concern about the child's weight and height being at the 5th percentile for his age. Given the child's medical history of a congenital heart defect, it is important for the nurse to address the mother's concerns and provide an accurate response.

The response that states "His smaller size is probably due to the heart disease" is appropriate because children with congenital heart defects may experience growth and developmental delays. Heart defects can affect the child's ability to obtain sufficient nutrients for growth, leading to slower weight and height gain. By acknowledging the relationship between the child's heart disease and his smaller size, the nurse provides the mother with an explanation for the child's growth pattern and helps alleviate concerns.

The other response options are not appropriate or helpful. Asking about the child's mental abilities or implying that the mother has not been feeding the child adequately can be perceived as judgmental or dismissive.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A.Tingling on the tongue or lips is an early sign of an allergic reaction to the contrast dye used during an intravenous pyelogram. This type of reaction can quickly progress to more severe symptoms, such as difficulty breathing and anaphylaxis, so it is crucial to recognize and respond to it promptly.

B. Episodes of shivering: Shivering is not typically an early sign of an allergic reaction to contrast dye. It might indicate a reaction to temperature or anxiety but is not as immediately concerning as symptoms of an allergic reaction.

C. Salty taste in the mouth: A salty or metallic taste is a common and benign side effect of the contrast dye and is not indicative of an adverse reaction.

D. Difficulty breathing: Difficulty breathing is a severe and later sign of an allergic reaction. By the time this symptom appears, the reaction has progressed and immediate intervention is necessary.

A. Viral meningitis whose temperature changed from 101° F (38.3°C) to 102° F (38.9° C). B. Myxedema coma whose blood pressure changed from 80/50 mm Hg to 70/40 mm Hg. C. Diabetic ketoacidosis whose Glasgow Coma Scale score changed from 10 to 7. D. Subdural hematoma whose blood pressure changed from 150/80 mm Hg to 170/60 mm Hg.

Correct Answer is A

Explanation

A) Correct- Viral meningitis is an inflammation of the meninges (the protective membranes surrounding the brain and spinal cord) caused by a viral infection. While it can be serious, it is generally less severe than bacterial meningitis. Monitoring the client's temperature is an important aspect of care, as changes in temperature can indicate the progression of the illness or the effectiveness of interventions. A temperature increase from 101°F to 102°F is a subtle change but may still require close monitoring and symptom management. The practical nurse (PN) is capable of monitoring vital signs, including temperature, and reporting any changes to the registered nurse (RN) or healthcare provider. It is within the PN's scope of practice to assess and report changes in vital signs and general condition. The other scenarios involve more complex clinical situations that may require the expertise of registered nurses.
B) Incorrect- Myxedema coma is a severe form of hypothyroidism and is considered a medical emergency. Managing and assessing a client with myxedema coma requires advanced assessment, critical thinking, and interventions that are typically within the scope of registered nurses.
C) Incorrect- Diabetic ketoacidosis (DKA) is a complex condition that requires frequent monitoring of blood glucose levels, electrolytes, vital signs, and assessment of the level of consciousness. The change in the Glasgow Coma Scale score indicates a neurological deterioration that requires immediate attention and intervention, making it suitable for a registered nurse.
D) Incorrect- A subdural hematoma is a serious neurological condition that requires close monitoring of vital signs and neurological status. The change in blood pressure indicates a potential change in intracranial pressure and should be managed by registered nurses with expertise in neurological care.

View Question and Answer

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

A 3-year-old boy with a congenital heart defect is brought to the clinic by his mother because he has a fever and an earache. During the assessment, the mother asks the nurse why her child is at the 5th percentile for weight and height for his age. Which response is best for the nurse to provide?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An adult client is admitted for severe pain in his side and back and is sent for an intravenous pyelogram. Which report from the client is the earliest indication to the nurse that the client is experiencing an adverse reaction to this procedure?

Correct Answer is A

Explanation

The charge nurse is making assignments for one practical nurse (PN) and three registered nurses (RN) who are caring for neurologically compromised clients. Which client with which change in status is best to assign to the PN?

Correct Answer is A

Explanation

A client develops urticaria on the trunk and neck shortly after a secondary infusion of piperacillin is initiated. In which, order should the nurse implement these interventions? (Arrange the actions in order of priority, with the highest priority first, and least priority last or at the bottom.)

A client with a history of lung cancer reluctantly comes to the clinic because of persistent hoarseness and a chronic cough. The client's respirations are labored when speaking and the capillary refill is 3 seconds. Which additional finding warrants intervention by the nurse?

The healthcare provider prescribes 500 mL intravenous (IV) bolus of 0.9% normal saline to be infused over 30 minutes. How many mL/hour should the nurse set the infusion pump? (Enter numerical value only.)

The school nurse is called to the soccer field because a child has a nose bleed (epistaxis). In which position should the nurse place the child?

An unlicensed assistive personnel (UAP) is assigned to a client with flu-like symptoms who has been placed on droplet precautions. The UAP requests a change in assignment, stating she has not yet been fitted for a particulate filter mask. Which action should the nurse take?

A client who is receiving zidovudine reports the appearance of pinpoint, red, round spots on the skin. Which result should the nurse report to the healthcare provider?

The nurse is caring for a client after a thoracentesis that drained 50 mL of clear fluid from the left lung. Which assessment finding should the nurse report to the healthcare provider immediately?