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.

Nursing Test Bank

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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.

A. Decreased attention span B. Hyperactivity C. Tachycardia D. Hypotension

Correct Answer is A

Explanation

A. Decreased attention span is a common manifestation of increased intracranial pressure, as pressure on the brain can affect cognitive function.

B. Hyperactivity is not typically associated with increased intracranial pressure. It would be more common for the child to exhibit lethargy or irritability.

C. Tachycardia is not a primary symptom of increased intracranial pressure. Typically, bradycardia (slow heart rate) is seen in cases of severe intracranial pressure.

D. Hypotension is not usually associated with increased intracranial pressure. In fact, increased intracranial pressure often leads to elevated blood pressure and a widening pulse pressure.

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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 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

A nurse is assessing a school-age child who has an infratentorial brain tumor. Which of the following findings should the nurse identify as a manifestation of increased intracranial pressure?

Correct Answer is A

Explanation

A parent calls the pediatric clinic to report that her child has a bloody nose. The nurse should give the parent which of the following instructions to stop the bleeding?

A nurse is gathering data on a 10-month-old infant. Which of the following findings should be reported to the provider?

A nurse is performing hearing screenings for children at a community health fair. Which of the following children should the nurse refer to a provider for a more extensive hearing Evaluation?

A nurse is caring for a 2-year-old child in an acute care setting. Which of the following vital signs require immediate notification to a primary care provider?

A nurse in the pediatric clinic is discussing Piaget's theory of cognitive development with a newly licensed nurse. The nurse should review which of the following types of thinking that occur during adolescent development?

A nurse is providing health promotion teaching to an adolescent. Which of the following is the leading cause of death among this age group?

When considering palliative care for a young child with a life-threatening illness, which is an important consideration?

Which therapeutic management treatment is implemented for children with Hirschsprung disease?

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.