A nurse is caring for a 10-year-old male child.
Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again.
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Body system |
Findings |
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Neurological |
Generalized muscle weakness noted in bilateral lower extremities. Child reports pain in legs on palpation, rates pain as 5 on a scale of 0 to 10. Patellar deep tendon reflexes 1+ bilaterally. Child is awake and alert, responds appropriately to questions. |
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Gastrointestinal |
Abdomen slightly firm, bowel sounds hypoactive. Reports last bowel movement was 3 days ago. |
Generalized muscle weakness noted in bilateral lower extremities
Child reports pain in legs on palpation, rates pain as 5 on a scale of 0 to 10
Abdomen slightly firm, bowel sounds hypoactive
Reports last bowel movement was 3 days ago
Child is awake and alert, responds appropriately to questions
The Correct Answer is ["A","B","C","D"]
Findings that require immediate follow-up:
- Generalized muscle weakness noted in bilateral lower extremities: This could indicate a neurological or muscular issue, such as Guillain-Barré Syndrome (GBS), which is a concern after a viral infection or vaccination. This requires further investigation and close monitoring for any signs of progression, such as worsening weakness or respiratory involvement.
- Child reports pain in legs on palpation, rates pain as 5 on a scale of 0 to 10: This pain could be indicative of muscle cramping or weakness, which may be associated with GBS or another neurological condition. Pain in combination with muscle weakness should be followed up closely.
- Abdomen slightly firm, bowel sounds hypoactive, and reports last bowel movement was 3 days ago: This could suggest constipation or a gastrointestinal issue. However, the gastrointestinal symptoms may be secondary to the muscle weakness (if part of a systemic condition like GBS), and should be monitored, but it’s not as urgent as the neurological findings.
Findings that do not require immediate follow-up:
- Patellar deep tendon reflexes 1+ bilaterally: A 1+ reflex is on the lower end of normal and does not indicate a severe problem by itself.
- Child is awake and alert, responds appropriately to questions: This is a reassuring sign and does not require immediate follow-up.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. 6 months: At this age, infants typically coo and babble but do not form words.
B. 10 months: Infants might say "mama" or "dada," but their vocabulary is usually less than 10 words.
C. 18 months: By 18 months, most children have a vocabulary of approximately 10–20 words.
D. 24 months: By 24 months, children typically have a vocabulary of about 50 words or more and begin forming two-word phrases.
Correct Answer is B
Explanation
A. Administer aspirin for pain. Aspirin increases the risk of bleeding and is contraindicated in clients with hemophilia. Acetaminophen is recommended instead.
B. Place knee pads on the child. Protective gear like knee pads can help prevent joint injuries, which are common in toddlers with hemophilia.
C. Perform passive range-of-motion exercises following an acute episode. Active range-of-motion exercises are preferred after an acute episode to prevent joint damage. Passive exercises can exacerbate bleeding.
D. Use a firm-bristled toothbrush for dental care. A soft-bristled toothbrush should be used to minimize gum bleeding.
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