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
Increased intracranial pressure
Upper extremity hypotension
Weak femoral pulses
The Correct Answer is D
A. Frequent nosebleeds: While hypertension can occur in coarctation of the aorta, frequent nosebleeds are not a typical finding associated with this condition.
B. Increased intracranial pressure: This is not a direct finding of coarctation of the aorta. Increased intracranial pressure may be related to other conditions, but it is not specifically expected in this context.
C. Upper extremity hypotension: In coarctation of the aorta, the upper extremities usually experience higher blood pressure due to the narrowing of the aorta distal to the branches supplying the arms. Therefore, hypotension in the upper extremities is not expected.
D. Weak femoral pulses: This is an expected finding in coarctation of the aorta, as the narrowing of the aorta can lead to decreased blood flow to the lower body, resulting in weak or diminished femoral pulses compared to the upper extremities.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Ambulate the client 48 hr after the procedure: Early ambulation is important to prevent complications such as deep vein thrombosis and promote recovery. However, ambulating the client 48 hours after the procedure may be too late. Early mobilization, usually within the first 24 hours, is encouraged.
B) Provide a soft diet on the first postoperative day: After gastric bypass surgery, the client typically starts with clear liquids and gradually progresses to a soft diet. Providing a soft diet on the first postoperative day is not appropriate and could cause complications.
C) Provide 60 mL (2 oz) of fluid intake every 5 min: Fluid intake should be carefully monitored and gradually increased. Providing 60 mL of fluid every 5 minutes is excessive and could lead to discomfort or complications such as dumping syndrome.
D) Measure and compare abdominal girth daily: Measuring and comparing abdominal girth daily helps monitor for signs of complications such as internal bleeding or anastomotic leaks. This intervention is crucial for early detection and prompt management of potential issues
Correct Answer is D
Explanation
A) Use clothing with buttons and zippers: This may create frustration for clients with dementia, who may struggle with complex clothing. Instead, simpler clothing options, like pull-on pants, may be more suitable.
B) Engage the client in activities that increase sensory stimulation: While some sensory stimulation can be beneficial, overwhelming sensory input may lead to confusion or agitation. It’s important to find a balance that suits the individual’s needs.
C) Discourage physical activity during the day: This is incorrect. Encouraging physical activity during the day can help improve mood, reduce restlessness, and promote better sleep at night.
D) Establish a toileting schedule for the client: This is the correct answer. A consistent toileting schedule can help manage incontinence and reduce anxiety related to bathroom needs, providing a sense of routine and security for clients with dementia.
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