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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 C

Explanation

A. Passive range of motion exercises are contraindicated during acute joint swelling and bleeding, as they can exacerbate bleeding into the joints (hemarthrosis).
B. Aspirin is contraindicated as it can impair platelet function and worsen bleeding in clients with bleeding disorders.
C.Offering an electronic tablet helps to distract the toddler and prevent unnecessary movement, which could worsen joint bleeding or discomfort.
D. Warm packs are contraindicated during acute joint swelling; cold packs should be used to reduce bleeding and swelling.

A. Nutritionist B. Speech therapist C. Physical Therapist D. Occupational Therapist

Correct Answer is A

Explanation

A. Nutritionist. The toddler’s BMI (28) indicates obesity, necessitating a referral for nutritional counseling to guide healthier dietary practices.
B. Speech therapist. The toddler demonstrates age-appropriate speech development, including forming short sentences such as "want go home now."
C. Physical therapist. The toddler meets gross motor developmental milestones such as running, kicking, and throwing a ball.
D. Occupational therapist. The toddler’s ability to feed themselves using finger foods and utensils indicates appropriate fine motor skills.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits A nurse is caring for a toddler on a pediatric unit. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

Exhibits A nurse is caring for a toddler in a pediatric clinic. Which of the following referrals should the nurse make?

Correct Answer is A

Explanation

A nurse is assessing a toddler. Which of the following findings should the nurse identify as an indication of potential child maltreatment?

A nurse is assessing a 9-month-old infant who has gastroenteritis. Which of the following findings should the nurse identify as a manifestation of severe fluid volume deficit?

A nurse is teaching an adolescent how to use a peak expiratory flow meter (PEFM). The nurse should identify that which of the following statements by the child indicates an understanding of the teaching?

The nurse is continuing to care for the infant. Exhibits The nurse has provided teaching to the parents about the prescribed medication. Which of the following statements by the parents indicate an understanding of the teaching? Select all that apply.

A nurse in an emergency department is caring for a school-age child. Exhibits The nurse is continuing to care for the child. Which of the following actions should the nurse plan to take? Select all that apply.