Which of the following findings indicate a potential complication that requires immediate follow-up? (Select All that Apply.)

Neurological assessment

Basic metabolic panel

Blood pressure/heart rate

Abdominal assessment

Complete blood count

Pain assessment

Answer and Explanation

Correct Answer : A,B,C,E,F

A. Neurological assessment is critical in identifying potential complications, especially in cases of head injury, infection, or brain-related conditions. A change in mental status or neurological findings (e.g., confusion, loss of consciousness) warrants immediate follow-up.

B. Basic metabolic panel provides key information on electrolyte imbalances, kidney function, and acid-base status. Imbalances or abnormalities, such as hyperkalemia or hyponatremia, can indicate life-threatening conditions.

C. Blood pressure/heart rate is crucial to monitor because abnormalities in these vital signs can indicate cardiovascular instability, shock, or autonomic dysfunction. Significant changes require immediate intervention.

D. Abdominal assessment is important but not always immediately urgent unless signs of acute abdominal issues (e.g., severe pain, distention, or bleeding) are present.

E. Complete blood count is essential for monitoring for signs of infection, anemia, or bleeding disorders. Abnormalities such as low hemoglobin or a high white blood cell count require further investigation.

F. Pain assessment is important but may not always indicate an immediate life-threatening issue. However, uncontrolled pain or new-onset severe pain can signal a complication, such as infection or tissue damage, which needs prompt attention.

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Correct Answer is B

Explanation

A. The tumor is located in the lower back of the brain in the midline posterior fossa is incorrect. This description is more characteristic of a cerebellar or brainstem tumor, not neuroblastoma.

B. The tumor originated in the adrenal glands is correct. Neuroblastoma typically arises from the adrenal glands, though it can also develop in nerve tissue along the spine, neck, chest, or pelvis.

C. The tumor has not spread to other areas of the child's body is incorrect. Neuroblastoma often metastasizes to other parts of the body, such as the bones, lymph nodes, liver, and skin.

D. The tumor came from malformation of astrocyte glial brain cells is incorrect. This describes gliomas, which are a different category of brain tumors, not neuroblastoma.

A. Keep the infant supine. B. Suction the mouth with an oral suction tube. C. Apply elbow restraints and release them periodically. D. Feed the infant with a spoon for 48 hours.

Correct Answer is C

Explanation

A. Keep the infant supine is incorrect. After cleft palate repair, it is generally recommended to keep the infant in a position that minimizes pressure on the surgical site. Keeping the infant in a supine position may cause pressure on the repaired area, so side or semi-prone positioning is preferred.

B. Suction the mouth with an oral suction tube is incorrect. Suctioning should be avoided unless absolutely necessary because it can irritate the surgical site and cause trauma to the newly repaired palate.

C. Apply elbow restraints and release them periodically is correct. Elbow restraints are commonly used after cleft palate surgery to prevent the infant from touching or putting pressure on the surgical site. These restraints should be periodically released to allow for movement and prevent skin breakdown.

D. Feed the infant with a spoon for 48 hours is incorrect. After cleft palate repair, feeding should be done carefully. Special feeding bottles or cups are typically used to avoid trauma to the surgical site. Feeding with a spoon may cause pressure on the repair and should be avoided.

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Which of the following findings indicate a potential complication that requires immediate follow-up? (Select All that Apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a child who has been diagnosed with malignant neuroblastoma. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

A nurse is caring for a 10-month-old infant who is 8 hours postoperative following cleft palate repair. Which of the following interventions should the nurse include in the infant's plan of care?

Correct Answer is C

Explanation

A nurse is assessing an infant following a motor vehicle crash. Which of the following findings should the nurse monitor to identify increased intracranial pressure?

A child is admitted with a suspected diagnosis of Wilms' tumor. The nurse should place a sign with which of the following warnings over the child's bed?

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A nurse enters a client's room and finds the client on the floor having a seizure. Which of the following actions should the nurse take?

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The nurse is providing teaching to the parents of a school-aged child newly diagnosed with Crohn's disease about dietary measures to implement during an exacerbation. Which statement made by the parents indicates a need for further instruction?

A child with a head injury is at risk for increased intracranial pressure (ICP). Which change in status would alert the nurse to believe an increase in ICP has occurred?