A nurse is caring for a child with coarctation of the aorta. On assessment the nurse finds stronger pulses in the upper extremities than in the lower extremities. The blood pressure In the child's arms is higher than in the child's legs. Which of the following is a priority Intervention the nurse should implement?

Administer intravenous antibiotics

Continue to monitor the child for complications

Prepare for a balloon angioplasty

Notify the cardiologist of the findings

Answer and Explanation

The Correct Answer is D

A.   Antibiotics are not indicated for coarctation of the aorta.
B.   Monitoring is important, but the immediate action is to notify the cardiologist for further intervention.
C.   Balloon angioplasty is a potential treatment for coarctation of the aorta but would be decided by the cardiologist after assessment.
D.   Coarctation of the aorta causes a narrowing of the aorta, leading to differences in blood pressure and pulse strength between the upper and lower extremities. The nurse should notify the cardiologist for further evaluation and management.

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Correct Answer is ["C","D","E","F"]

Explanation

A. Pyloric stenosis is unrelated to TOF. It involves the narrowing of the pyloric valve in the stomach and is not a defect associated with TOF.
B. LVH is not typically a feature of TOF, as the primary issues affect the right ventricle.
C. Right ventricular hypertrophy occurs due to the obstruction of blood flow through the pulmonary valve in TOF.
D. In TOF, the aorta is positioned directly over the ventricular septal defect (VSD), which is known as overriding aorta.
E. A VSD is a key component of TOF, where there is a hole between the ventricles, allowing oxygen-poor and oxygen-rich blood to mix.
F. Pulmonary stenosis (narrowing of the pulmonary valve) is one of the hallmark defects in TOF.

A. Oliguria B. Negative Kernig's sign C. Bulging fontanel D. Negative Brudzinski sign

Correct Answer is C

Explanation

A. Oliguria (decreased urine output) may be a sign of dehydration or kidney dysfunction but is not typically the primary symptom of a CNS infection.
B. A negative Kernig's sign (no resistance to leg extension) is a reassuring sign and suggests that meningitis or other CNS infections are less likely. A positive sign would suggest possible meningitis.
C. Bulging of the fontanel is a sign of increased intracranial pressure, which can occur in CNS infections such as meningitis. This is a critical finding that requires immediate attention.
D. A negative Brudzinski sign means there is no neck stiffness or pain when the neck is flexed, which is a good finding. A positive sign would suggest the presence of meningitis.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a preschool client who has Tetralogy of Fallot (TOF). What are the defects the nurse should be aware of when caring for a client with Teratology of Fallot (TOF)? (Select all that apply).

Correct Answer is ["C","D","E","F"]

Explanation

A nurse is assessing a five-month-old Infant. The nurse should recognize that which of the following manifestations is associated with a central nervous system (CNS) Infection?

Correct Answer is C

Explanation

A nurse is caring for a child who has undergone a Ventriculoperitoneal (VP) shunt placement procedure. The nurse is aware of the need for careful prioritization of care. Which of the following actions should the nurse prioritize for this child?

The nurse is taking care of a child with scables. Which primary clinical manifestation should the nurse expect to assess with this disease?

A nurse is admitting a child diagnosed with leukemia and is scheduled to receive chemotherapy for the Intensification stage of treatment. Which of the following clients should the nurse place in the same room with this child?

A nurse is caring for a child with Osteogenesis Imperfecta type 3. Which of the following interventions should the nurse implement for this child? SELECT ALL THAT APPLY

The nurse is admitting a child with rheumatic fever. Which therapeutic management should the nurse expect to Implement?

A nurse is caring for a 2-month-old infant with epispadias post-op surgical revision with a stent placement. What interventions should the nurse expect during post op care?

A nurse is assessing a 5-month-old infant who has had a seizure and high pitched crying with a high fever. The nurse anticipates the need for which diagnostic testing?

A nurse is caring for a 6-month-old Infant with a diagnosis of Tetralogy of Fallot (TOF) who is experiencing a hypercyanotic spell. The Infant is lethargic and has a weak cry. What is the priority nursing action for this Infant?