Exhibits

The nurse reviews the client’s medical record from admission to 1930 hrs. Click to indicate whether the assessment finding has improved or not changed.

Dyspnea

Heart rate

Blood pressure

Oxygen saturation

Respiratory rate

Oral intake

Lung sounds

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"},"G":{"answers":"B"}}

Assessment Finding	Improved	No change
Dyspnea		✅
Heart rate	✅
Blood pressure	✅
Oxygen saturation	✅
Respiratory rate	✅
Oral intake	✅
Lung sounds		✅

Rationale:

Improved:

Heart rate and blood pressure are slightly improved by 1930, likely due to the medications (furosemide, enalapril) helping manage fluid retention and blood pressure.

Oral intake has improved, but monitoring of this is critical given the recent lack of eating for several days.

No change:

Dyspnea remains unchanged, since the adolescent is still dyspneic with activity.

Lung sounds remain unchanged, indicating that there may still be some wheezing or fluid buildup in the lungs.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Constipation is not typically associated with sickle cell crisis. While it can occur due to medications or dehydration, it is not a primary symptom of a crisis.

B. Bradycardia is not a typical manifestation of sickle cell crisis. The patient might experience tachycardia due to pain or dehydration.

C. Pain is the hallmark symptom of a sickle cell crisis. The sickle-shaped red blood cells obstruct blood flow, leading to ischemia and severe pain, often in the joints or abdomen.

D. Fever can occur if there is an infection, but pain is the most characteristic finding in a sickle cell crisis.

A. Encopresis B. Pyloric stenosis C. Hirschsprung's disease D. Enterocolitis

Correct Answer is C

Explanation

A. Encopresis refers to the inappropriate passage of stool, typically seen in children with chronic constipation. It is not associated with mechanical obstruction.

B. Pyloric stenosis involves a narrowing of the pyloric sphincter, leading to projectile vomiting rather than a mechanical obstruction of the intestines.

C. Hirschsprung's disease involves inadequate motility of part of the colon due to a lack of ganglion cells, leading to a mechanical obstruction.

D. Enterocolitis refers to inflammation of the intestines and is not a primary cause of mechanical obstruction.

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Exhibits The nurse reviews the client’s medical record from admission to 1930 hrs. Click to indicate whether the assessment finding has improved or not changed.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A pediatric client in sickle cell crisis comes to the hospital with his mother. When assessing the client, the nurse should expect to find which of the following manifestations?

Correct Answer is C

Explanation

A nurse is caring for an infant who has inadequate motility of part of the intestine resulting in a mechanical obstruction. The nurse should identify this finding as a manifestation of which of the following disorders?

Correct Answer is C

Explanation

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

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A nurse is caring for a child who has rheumatic fever. When obtaining the child's medical history from the parent, the nurse should recognize the significance of which of the following data as the possible source of the child's infection?

Exhibits

The nurse reviews the client’s medical record from admission to 1930 hrs. Click to indicate whether the assessment finding has improved or not changed.