The nurse is reviewing the history and physical notes, as well as the nurse’s notes and laboratory results for a child.
The child is developmentally appropriate, interacting with his parents, and is in the percentile for weight and height.
The child’s lung sounds are clear and equal, a murmur is noted upon auscultation, and clubbing of the fingers is observed.
There is no skin breakdown, and the mucous membranes are pink and moist.
What condition is the child most likely experiencing, what two actions should the nurse take for this condition, and what two parameters should the nurse monitor to assess the child’s progress?

Polycythemia.

Temperature.

Answer and Explanation

The Correct Answer is A

Choice A rationale

The child’s symptoms, including clear and equal lung sounds, a murmur upon auscultation, and clubbing of the fingers, suggest a condition affecting the heart and lungs. Polycythemia, a condition characterized by an increased number of red blood cells, could explain these symptoms. The nurse should monitor the child’s hematocrit and hemoglobin levels, as these can be elevated in polycythemia. The nurse should also monitor the child’s oxygen saturation, as hypoxia can occur in polycythemia3.

Choice B rationale

While temperature is an important vital sign to monitor in any patient, it does not directly address the child’s symptoms or the likely underlying condition. Therefore, it is not the most relevant choice in this scenario3. Diabetic ketoacidosisDiabetic ketoacidosis Explore

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Correct Answer is C

Explanation

Choice A rationale

Discussing moving to Hawaii does not necessarily indicate a connection to the client’s current condition. It could be a long-term plan or a dream.

Choice B rationale

Being unemotional when talking about needing to rebuild their house could indicate a coping mechanism or emotional detachment. However, without additional context, it’s difficult to definitively associate this behavior with their current condition.

Choice C rationale

Expressing a desire to be in a quieter area of the unit could indicate that the client is experiencing stress, anxiety, or discomfort in their current environment. This behavior is most likely associated with their current condition as it shows a direct response to their surroundings.

Choice D rationale

Requesting sleeping medication for the night could indicate various issues such as insomnia, anxiety, or other sleep-related disorders. However, without more information about the client’s current condition, it’s not possible to make a direct association.

A. Altered taste sensation. B. Fatigue. C. Pain during eating. D. Nausea.

Correct Answer is C

Explanation

Choice A rationale

While altered taste sensation can occur with radiation treatment, it’s not the most likely reason for an imbalance in nutritional intake in this scenario.

Choice B rationale

Fatigue can be a side effect of radiation treatment, but it’s not the primary reason for an imbalance in nutritional intake in this case.

Choice C rationale

Pain during eating is the most likely cause of imbalanced nutritional intake in this scenario. The patient’s laryngeal cancer and the development of mucositis indicate that eating is likely painful for them. This discomfort can significantly deter the patient from eating, leading to decreased nutritional intake.

Choice D rationale

Nausea can occur with radiation treatment, but it’s not the primary reason for an imbalance in nutritional intake in this case.

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Naxlex Comprehensive Predictor Exams

Which client statement or behavior is most likely associated with their current condition?

Correct Answer is C

Explanation

A patient undergoing radiation treatment for laryngeal cancer has developed xerostomia and mucositis, leading to an imbalance in nutritional intake.What is the most likely reason for this issue?

Correct Answer is C

Explanation

A patient informs the nurse about starting an exercise program a month ago to lose weight and improve sleep.The patient states, “It still takes at least two hours to fall asleep at night.”. What action should the nurse take?

An older adult client with dementia is refusing to allow an unlicensed assistive personnel (UAP) to assist in bathing.The client is becoming increasingly agitated and stating the UAP “wants to hurt me and tie me up.”. Which approach should the nurse use with this client?

While caring for a client with a full thickness burn covering 40% of the body surface area (BSA), the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, which of the client’s laboratory values should the nurse note?

A patient with primary hypothyroidism is showing early signs of myxedema coma. In what order should the nurse perform the following assessments? (Rank the first action at the top with the remainder in descending order.)

A parent brings their 2-month-old infant to the clinic to receive the recommended primary vaccines.Which instruction should the nurse provide the parent about care of the infant after the injections?

A young adult is admitted to the emergency department after consuming an unknown quantity of drugs.The patient is unresponsive, and an endotracheal tube (ETT) has been inserted.What methods should the nurse use to confirm the correct placement of the ETT? Select all that apply.

Which of the following symptoms reported by a patient taking lovastatin should the nurse prioritize for immediate follow-up?