A nurse is caring for an infant who has coarctation of the aorta.
Which of the following should the nurse identify as an expected finding?
Frequent nosebleeds.
Upper extremity hypotension.
Weak femoral pulses.
Increased intracranial pressure.
The Correct Answer is C
This is because coarctation of the aorta is a congenital condition where the aorta is narrow, usually in the area where the ductus arteriosus inserts. This causes a decrease in blood flow to the lower body, resulting in weak or absent pulses in the femoral arteries.
The other choices are incorrect for the following reasons:
Choice A is not a typical sign of coarctation of the aorta.
Nosebleeds can be caused by many factors, such as dry air, allergies, trauma, or bleeding disorders.
Choice B is also not a common finding in coarctation of the aorta. In fact, patients with this condition may have high blood pressure in the upper extremities due to the increased resistance of the narrowed aorta.
Choice D is not directly related to coarctation of the aorta.
Increased intracranial pressure can be caused by various conditions that affect the brain, such as head injury, stroke, infection, or tumor.
Normal ranges for blood pressure and pulse vary depending on age, sex, and health status. However, some general guidelines are:
- Blood pressure: less than 120/80 mmHg for adults; less than 95/65 mmHg for infants.
- Pulse: 60 to 100 beats per minute for adults; 100 to 160 beats per minute for infants.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Comparing the client’s current weight with preprocedure weight is the best way to evaluate the effectiveness of the paracentesis, which is a procedure to remove excess fluid from the abdominal cavity. The fluid buildup, or ascites, is a common complication of end-stage liver disease (ESLD), which is a condition in which the liver is severely damaged and cannot function adequately.
Choice B is wrong because examining for leakage at the site of the procedure is not a measure of effectiveness, but a potential complication that should be monitored and reported.
Choice C is wrong because checking the client’s serum albumin levels is not relevant to the paracentesis.
Albumin is a protein that helps maintain fluid balance in the body, but it is not affected by the removal of fluid from the abdomen.
Choice D is wrong because confirming that the client is able to urinate is not related to the paracentesis.
Urination is a function of the kidneys, not the liver, and it does not reflect the amount of fluid removed from the abdomen.
Correct Answer is A
Explanation
Absence seizures are brief, sudden lapses of consciousness that usually last a few seconds. They are more common in children than in adults.
A person having an absence seizure may stare blankly into space and not respond to others. They may also have subtle movements such as lip smacking or eyelid fluttering.
Choice B is wrong because absence seizures typically last less than 15 seconds, not 30 to 60 seconds.
Choice C is wrong because absence seizures have a sudden onset, not a gradual one.
Choice D is wrong because absence seizures do not have an aura prior to onset. An aura is a warning sign that some people experience before a seizure, such as a strange feeling, smell, or vision.
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