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A nurse is caring for a 10-year-old male child.

Exhibits

Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again.

Body system

Findings

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.

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

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. The child's BMI: Children with cystic fibrosis often have difficulty absorbing nutrients due to pancreatic insufficiency. Monitoring the child's BMI provides a good overall indicator of nutritional status, as it accounts for both weight and height.
B. The child's pancreatic enzyme dose: While important, the enzyme dose is adjusted to help the child digest food, but it does not directly assess nutritional status.
C. The child's diet: The diet is important, but it doesn't provide a direct, quantifiable measure of nutritional status. It's more of a management tool.
D. The child's stool analysis: Stool analysis can help assess malabsorption, but it does not directly reflect overall nutritional status in terms of growth or weight gain.

A. Warm extremities B. Frequent headaches C. Distended neck veins D. Weight loss

Correct Answer is C

Explanation

A. Warm extremities: Typically, in heart failure, extremities can feel cold due to poor circulation and reduced cardiac output.
B. Frequent headaches: Headaches are not a typical sign of heart failure in children. Although they can occur in some cases due to increased intracranial pressure, they are not characteristic of heart failure.
C. Distended neck veins: Distended neck veins are a hallmark sign of right-sided heart failure. It occurs when the heart is unable to efficiently pump blood, leading to congestion and fluid retention, which can cause blood to back up into the veins, resulting in visible distention.
D. Weight loss: Weight gain due to fluid retention is more common in heart failure. Weight loss may occur in more advanced or chronic cases due to decreased appetite and fluid shifts, but weight gain is the expected finding in early stages.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an outpatient clinic is caring for a school-age child who has cystic fibrosis. Which of the following findings should the nurse monitor as the best indication of the child's nutritional status?

Correct Answer is A

Explanation

A nurse is assessing a child who has heart failure. Which of the following clinical manifestations should the nurse expect?

Correct Answer is C

Explanation

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