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 C
Explanation
This is because tight-fitting underwear can trap moisture and create a favorable environment for bacterial growth, which can increase the risk of urinary tract infections (UTIs) . Loose-fitting underwear can allow air circulation and prevent moisture accumulation .
Choice A is wrong because drinking four 240 mL (8 oz) glasses of water each day is not enough to prevent UTIs. The recommended amount of water intake for adults is about 2 to 3 liters per day . Drinking enough water can help flush out bacteria from the urinary tract and prevent them from adhering to the bladder wall .
Choice B is wrong because voiding every 5 to 6 hours during the day is too infrequent and can increase the risk of UTIs. The nurse should advise the client to void every 2 to 3 hours during the day. This can help prevent urinary stasis and bacterial multiplication in the bladder .
Choice D is wrong because taking a bubble bath after intercourse can increase the risk of UTIs. The nurse should instruct the client to avoid bubble baths, vaginal douches, or sprays, as they can irritate the urethra and introduce bacteria into the urinary tract . The nurse should also advise the client to empty the bladder before and after sexual intercourse, as this can help remove bacteria that may have entered the urethra during sexual activity .
Correct Answer is C
Explanation
This is because the Glasgow Coma Scale (GCS) is a tool to assess the level of consciousness and neurological status of a client who has a closed head injury. The GCS score can help guide the priority of interventions and the need for further diagnostic tests.
Choice A is wrong because an MRI of the brain is not the first action to take for a client who has a closed head injury. An MRI may be indicated later to evaluate the extent of brain damage, but it is not an emergency procedure.
Choice B is wrong because mannitol IV bolus is a medication that reduces intracranial pressure (ICP) by drawing fluid out of the brain tissue. However, mannitol should not be administered before confirming the presence and degree of increased ICP, which can be done by measuring the GCS score and other vital signs.
Choice D is wrong because inserting an indwelling urinary catheter for the client is not the first action to take for a client who has a closed head injury. A urinary catheter may be needed to monitor fluid balance and renal function, but it is not an urgent intervention.
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