A nurse in an emergency department is assessing an adolescent who reports inhalation of gasoline.
Which of the following findings should the nurse expect?
Pinpoint pupils
Hypothermia
Ataxia
Hyperactive reflexes
The Correct Answer is C
Choice A rationale
Pinpoint pupils are not a typical finding in an adolescent who has inhaled gasoline. Pinpoint pupils are more commonly associated with opioid use.
Choice B rationale
Hypothermia is not a typical finding in an adolescent who has inhaled gasoline. Inhalation of gasoline can cause central nervous system depression, leading to symptoms such as dizziness, confusion, and ataxia.
Choice C rationale
Ataxia, or lack of muscle coordination, can occur after inhaling gasoline. The gasoline vapors can depress the central nervous system, leading to symptoms such as dizziness, confusion, and ataxia.
Choice D rationale
Hyperactive reflexes are not a typical finding in an adolescent who has inhaled gasoline. Inhalation of gasoline can cause central nervous system depression, leading to symptoms such as dizziness, confusion, and ataxia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
A rectal body temperature of 37.3 C (99.1 F) in a school-age child is within the normal range, so it does not need to be reported.
Choice B rationale
A heart rate of 68/min in an 18-month-old toddler is below the normal range (80-130 beats per minute). This could indicate a serious condition such as heart block or hypothermia and should be reported to the provider.
Choice C rationale
A blood pressure of 132/82 mm Hg in an adolescent is slightly elevated but within acceptable limits for a teenager, especially if the teenager was nervous or anxious during the measurement.
Choice D rationale
A respiratory rate of 36/min in a 3-month-old infant is within the normal range (30-60 breaths per minute), so it does not need to be reported.
Correct Answer is A
Explanation
Choice A rationale
A creatinine level of 1.4 mg/dL is higher than the normal range and could indicate kidney damage, which is a known side effect of gentamicin. Therefore, the nurse should notify the healthcare provider.
Choice B rationale
A creatinine level of 0.3 mg/dL is within the normal range, so it would not typically be a cause for concern.
Choice C rationale
A BUN level of 12 is within the normal range, so it would not typically be a cause for concern.
Choice D rationale
A BUN level of 6 is within the normal range, so it would not typically be a cause for concern.
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