A nurse is receiving a change-of-shift report for a group of clients.
Which of the following clients should the nurse plan to see first?
A toddler who has coarctation of the aorta and weak pedal pulses.
A school-age child who has rheumatic fever and an increased erythrocyte sedimentation rate.
A school-age child who has endocarditis and a new onset of lethargy.
A toddler who has Kawasaki disease and erythema of the lips.
The Correct Answer is C
Choice A rationale
Weak pedal pulses in coarctation of the aorta indicate impaired blood flow distal to the narrowed area but do not indicate immediate deterioration. Chronic coarctation causes gradual compensatory mechanisms, and absent urgent changes, this case is less critical compared to acute presentations in other choices.
Choice B rationale
Rheumatic fever elevates erythrocyte sedimentation rate (ESR) due to inflammation, but this alone does not indicate acute danger. ESR reflects systemic inflammation rather than life-threatening symptoms, which makes this patient a lower priority unless accompanied by other significant changes.
Choice C rationale
New onset lethargy in endocarditis suggests possible septic emboli or worsening infection, which can rapidly progress to critical complications. Lethargy often indicates systemic compromise or reduced perfusion, which requires immediate attention compared to chronic or stable cases in other options.
Choice D rationale
Kawasaki disease presents erythema of the lips due to systemic vasculitis, but this finding alone does not indicate acute deterioration. The condition is serious but relatively stable without additional evidence of impending coronary complications, making this client less urgent than Choice C.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Gradually increasing lactose products is not recommended for lactose-intolerant individuals, as it can exacerbate symptoms like bloating, diarrhea, and abdominal pain. Avoiding or substituting lactose-containing foods is more effective in preventing discomfort.
Choice B rationale
Limiting calcium-fortified orange juice is not necessary, as it does not contain lactose. Such products provide a valuable alternative source of calcium, which is important for bone health in lactose-intolerant individuals.
Choice C rationale
Rice milk is a suitable alternative to cow’s milk for individuals with lactose intolerance, as it is lactose-free. This substitution helps maintain adequate nutritional intake without triggering symptoms associated with lactose digestion.
Choice D rationale
Flavored yogurts often contain added sugars, which may not appeal to some lactose-intolerant individuals. Additionally, not all yogurts are equally tolerated; plain yogurt with live cultures is typically better tolerated due to the presence of lactase-producing bacteria. .
Correct Answer is C
Explanation
Choice A rationale
Bounding peripheral pulses are characteristic of conditions like patent ductus arteriosus or hyperdynamic circulation, not heart failure. Heart failure often causes reduced cardiac output, resulting in weaker pulses. Peripheral vasoconstriction may occur as a compensatory mechanism.
Choice B rationale
Increased blood pressure is not typical in infants with heart failure. Instead, reduced cardiac output usually leads to hypotension or low systolic pressure. Hypertension is more associated with renal disorders or endocrine dysfunctions.
Choice C rationale
Tachycardia is a common manifestation of heart failure as the heart attempts to compensate for diminished cardiac output. Increased heart rate aids in maintaining adequate systemic circulation despite impaired myocardial function.
Choice D rationale
Increased urinary output is inconsistent with heart failure. Reduced cardiac output causes diminished renal perfusion, leading to decreased urine production or potential fluid retention and edema.
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