Bounding pulses in the arms Coarctation of the aorta, a narrowing or constriction of the descending aorta, causes increased flow to the upper extremities (increased pressure and pulses)
2.Answer B
Weight gain is associated with CHF and congenital heart deficits.
3.Answer D
half-strength hydrogen peroxide is recommended for cleansing the suture line after cleft lip repair.The bubbling action of the hydrogen peroxide is effective for removing debris. Normal saline also may be used. Mouthwashes frequently contain alcohol which can be irritating. Povidone-iodine solution is not used because iodine contained in the solution can be absorbed through the skin, leading to toxicity. A mild antiseptic solution has some antibacterial properties but is ineffective in removing suture-line debris.
4.Answer B
tissue hypoxia occurs as a result of the decreased oxygen-carrying capacity of the red blood cells. The sickled cells begin to clump together, which leads to vascular occlusion.
5.Answer A
Failure to pass meconium within the first 24 hours after birth may be an indication of Hirschsprung disease, a congenital anomaly resulting in mechanical obstruction due to inadequate motility in an intestinal segment. Failure to pass meconium is not associated with celiac disease, intussusception, or abdominal wall defect.
6.Answer D
for a child with arthritis associated with rheumatic fever, the joints are usually so tender that even the weight of bed linens can cause pain. Use of the bed cradle is recommended to help remove the weight of the linens on painful joints. Joints need to be maintained in good alignment, not positioned in extension, to ensure that they remain functional.Applying gentle traction to the joints is not recommended because traction is usually used to relieve muscle spasms, not typically associated with rheumatic fever. Supporting the body in good alignment and changing the client's position are recommended, but these measures are not likely to relieve pain.
7.Answer B
potato, peas, chicken, green vegetables, and rice cereal contain significant amounts of iron
and therefore would be recommended. Milk and yellow vegetables are not good iron sources.
Rice, by itself also is not a good source of iron.
8.Answer D
GER is the backflow of gastric contents into the esophagus resulting from relaxation or incompetence of the lower esophageal (cardiac) sphincter. No alteration in the oral mucous membranes occurs with this disorder. Fluid volume deficit, risk for aspiration, and altered nutrition are appropriate nursing diagnoses
9.Answer B.
Side-lying — CORRECT: most effective to facilitate drainage of secretions from the
mouth and pharynx; reduces possibility of airway obstruction. Supine — increased risk for aspiration, would not facilitate drainage of oral secretions Prone — risk for airway obstruction and aspiration, unable to observe the child for signs of bleeding such as increased swallowing Sims’ — on side with top knee flexed and thigh drawn up to chest and lower knee less sharply flexed: used for vaginal or rectal examination
10.Answer D
Do not administer pain medication or start a central line without MD orders.
11.Answer A
"Touching the abdomen could cause cancer cells to spread." Manipulation of the abdomen can lead to dissemination of cancer cells to nearby and distant areas. Bathing and turning the child should be done carefully. The other options are similar but not the most specific.
12.Answer B
Dehydration Clinical findings dehydration include lethargy, irritability, dry skin, and increased pulse.
13.Answer A
Measure head circumference In meningitis, assessment of neurological signs should be done frequently. Head circumference is measured because subdural effusions and obstructive hydrocephalus can develop as a complication of meningitis. The client will have already been on airborne precautions and crib top applied to bed on admission to the unit.
14.Answer B
Tissue hypoxia When the hemoglobin falls sufficiently to produce clinical manifestations, the findings are directly attributable to tissue hypoxia, a decrease in the oxygen carrying capacity of the blood.
15.Answer B
Explain the surgery 1 week prior to the procedure A 5 year-old can understand the surgery, and
should be prepared well before the procedure.Most of these procedures are "same day"surgeries and do not require an overnight stay.
16.Answer D
Note patterns of increased blood pressure Hypertension is a key assessment in the course of the disease.
17.Answer C
Continue with the present formula The recommended age for switching from formula to whole milk is 12 months. Switching to cow''s milk before the age of 1 can predispose an infant to allergies and lactose intolerance.
18.Answer C:
Clothing has become tight around the waist Parents often recognize the increasing
abdominal girth first. This is an early sign of Wilm''s tumor, a malignant tumor of the kidney.
19.Answer C:
"Thin, tenacious secretions from the lungs are a constant struggle in cystic fibrosis." All of the options will be concerns with cystic fibrosis,however the respiratory threats are the major concern in these clients. Other information of interest is that cystic fibrosis is an autosomal recessive disease. There is a 25% chance that each of these parent''s pregnancies will result in a child with systic fibrosis.
20.Answer is B:
Flexion of the hip and knees with passive flexion of the neck. A positive Brudzinski’s sign—flexion of hip and knees with passive flexion of the neck;a positive Kernig’s sign—inability to extend the knee to more than 135 degrees, without pain behind the knee, while the hip is flexed usually establishes the diagnosis of meningitis
21.Answer A
Because croup cause upper airway obstruction,inspiratory stridor is predominant symptom
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