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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. Educate the infant's caregiver about the feeding: While important, education should occur after ensuring the prescription is correct.
B. Flush the feeding tube before the feeding: This ensures patency but should only be done after verifying the prescription.
C. Clarify the feeding prescription with the provider. Bolus feedings are typically contraindicated with nasojejunal tubes because the jejunum cannot handle large volumes at once. Continuous feedings are usually prescribed. The prescription should be clarified before proceeding.
D. Place a label on the feeding bag and tubing: Labeling is necessary for safety but is not the priority when the prescription may be inappropriate.

A. "I should eat extra food on busy days when I am more active." B. "I should increase my intake of sugar-free fluids when I am sick." C. "I should eat a snack 30 minutes before my baseball game starts." D. "I should wait 2 hours after eating before playing with my friends." E. "I should have a 16-ounce glass of milk if I start feeling weak or shaky."

Correct Answer is ["A","B","C"]

Explanation

A. "I should eat extra food on busy days when I am more active." Physical activity lowers blood glucose levels. Eating extra food prevents hypoglycemia during periods of increased activity.
B. "I should increase my intake of sugar-free fluids when I am sick." During illness, maintaining hydration is essential. Sugar-free fluids help prevent dehydration without causing hyperglycemia.
C. "I should eat a snack 30 minutes before my baseball game starts." A pre-activity snack helps maintain blood glucose levels during exercise, reducing the risk of hypoglycemia.
D. "I should wait 2 hours after eating before playing with my friends." There is no need to delay physical activity for 2 hours after eating unless instructed otherwise by a healthcare provider.
E. "I should have a 16-ounce glass of milk if I start feeling weak or shaky." A smaller portion of fast-acting carbohydrates, like 4 ounces of juice or 15 grams of glucose tablets, is recommended for treating hypoglycemia.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for an infant who is not tolerating enteral feeding through a nasogastric tube. The provider inserts a nasojejunal feeding tube and prescribes bolus enteral feedings. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A school nurse is providing dietary teaching for an 11-year-old child who has type 1 diabetes mellitus. The nurse should identify which of the following responses by the child indicates an understanding of the teaching? Select all that apply.

Correct Answer is ["A","B","C"]

Explanation

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