A nurse is performing a physical assessment for a 13-year-old adolescent. Which of the following actions should the nurse take?
Have the child bend forward at the waist and check for asymmetry of the scapula.
Auscultate the abdomen for at least 1 min if bowel sounds are absent.
Use the FACES scale to assess pain.
Observe abdominal movement to determine the respiratory rate.
The Correct Answer is A
A. "Have the child bend forward at the waist and check for asymmetry of the scapula." This maneuver is known as the Adam's forward bend test and is used to screen for scoliosis, which commonly appears during adolescence.
B. "Auscultate the abdomen for at least 1 min if bowel sounds are absent." If bowel sounds are absent, the nurse should listen for at least 5 minutes in each quadrant before concluding they are truly absent.
C. "Use the FACES scale to assess pain." The FACES scale is typically used for younger children (3-7 years old). Adolescents can usually use a numeric rating scale (0-10) for pain assessment.
D. "Observe abdominal movement to determine the respiratory rate." Abdominal breathing is characteristic of infants and younger children. In adolescents, the nurse should observe chest movement to assess respiratory rate.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"}}
Explanation
Temperature: The temperature decreased from 38.8° C (101.8° F) to 37.6° C (99.7° F), which indicates a potential improvement in the infection response as the body temperature is coming down.
WBC count: The WBC count increased slightly from 14,000/mm³ to 15,000/mm³, which is still elevated compared to the normal range (5,000 to 10,000/mm³). This suggests that the body is still responding to infection and could indicate a worsening condition if the trend continues or remains elevated.
Weight-bearing ability on the affected leg: The improvement in weight-bearing ability suggests that the condition of the leg is improving. This indicates that the condition is improving as the pain or swelling may have decreased.
Wound assessment: The wound culture is still pending, and although there is no specific description provided, a pending culture and the general condition of the wound (which can be assessed for redness, warmth, or exudate) might still indicate a worsening condition if there is continued inflammation or signs of spreading cellulitis.
Correct Answer is A
Explanation
A. Give the child 3 to 6 oz of orange juice. The child's altered mental status, diaphoresis, and tremors indicate hypoglycemia. The best initial treatment for mild to moderate hypoglycemia is a fast-acting carbohydrate, such as orange juice (3 to 6 oz) to rapidly raise blood glucose levels.
B. Give the child a candy bar. While candy contains sugar, it also contains fat, which slows glucose absorption, delaying the correction of hypoglycemia.
C. Administer glucagon to the vastus lateralis. Glucagon is used for severe hypoglycemia (e.g., unconsciousness or seizures), not for mild to moderate symptoms.
D. Administer D5W intravenous fluids. IV dextrose is used in severe cases where the child is unconscious or unable to take oral glucose. Since this child is conscious, oral treatment is preferred.
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