How it Works
Try Naxlex NCLEX-RN (Free-Trial)

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.

A.

Generalized muscle weakness noted in bilateral lower extremities

B.

Child reports pain in legs on palpation, rates pain as 5 on a scale of 0 to 10

C.

Abdomen slightly firm, bowel sounds hypoactive

D.

Reports last bowel movement was 3 days ago

E.

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.


Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is D

Explanation

A. "Chill the medication prior to administration." The medication should be warmed to room temperature to prevent discomfort or dizziness during administration.
B. "Pull the pinna up and back during medication administration." For infants, the pinna should be pulled down and back to straighten the ear canal.
C. "Hyperextend the infant's neck during medication administration." Hyperextending the neck is unnecessary and may cause discomfort; a neutral position is sufficient.
D. "Massage the anterior area of the ear following administration." Massaging the tragus helps ensure the medication is evenly distributed into the ear canal.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

Explanation

1. Failure to thrive: The infant has poor weight gain despite being hungry after vomiting. Projectile vomiting, as described, often leads to insufficient caloric intake, putting the infant at risk for failure to thrive.

2. Dehydration: Repeated vomiting results in fluid loss, putting the infant at high risk of dehydration, which is common in conditions like pyloric stenosis, suspected here due to the symptoms and palpable abdominal mass.

3. Intussusception typically presents with intermittent, severe abdominal pain, "currant jelly" stools, and sometimes a sausage-shaped mass, which are not noted in this scenario.

4. Meckel diverticulum can cause painless rectal bleeding or obstruction symptoms but is not associated with projectile vomiting or a palpable mass.

5. Hirschsprung disease presents with failure to pass meconium, abdominal distension, and chronic constipation rather than the projectile vomiting seen here.

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Register