Week 4 HESI/ EAQs Flashcards
During a physical assessment of an at-risk patient, the nurse notes generalized edema, crackles at the base of the lungs, and some pulse irregularity. These are most likely signs of which condition?
Euglycemia
Pneumonia
Rheumatic fever
Cardiac decompensation
Cardiac decompensation
The nurse is caring for an infant with breathing difficulty. Upon auscultating the infant, the nurse finds that the infant has a murmur. What suggestion does the nurse give to the parents about infant care?
“Use formula milk.”
“Additional cardiac testing is necessary.”
“The infant should be wrapped in a thick blanket.”
“Maintain skin-to-skin contact with the mother.”
“Additional cardiac testing is necessary.”
The nurse evaluates the blood pressure (BP) of a neonate and suspects a cardiac defect. What recordings of the neonate’s BP confirm a cardiac defect?
The BP in the lower extremities is 60/40 mm Hg and in the upper extremities is 70/50 mm Hg.
The BP in the lower extremities is 50/40 mm Hg and in the upper extremities is 80/70 mm Hg.
The BP in the lower extremities is 70/40 mm Hg and in the upper extremities is 60/40 mm Hg.
The BP in the lower extremities is 80/40 mm Hg and in the upper extremities is 70/60 mm Hg.
The BP in the lower extremities is 50/40 mm Hg and in the upper extremities is 80/70 mm Hg.
The nurse observes on the cardiac monitor that a child admitted with diabetic ketoacidosis has a widening of the QT interval and the appearance of U wave after a flattened T wave. Which would the nurse conclude from such an observation?
The child has hypokalemia.
The child has hypovolemia.
The child has hypercalcemia.
The child has hyperkalemia.
The child has hypokalemia.
For which reason would an infant with cyanosis undergo a hyperoxia test?
To identify the presence of congenital defects
To confirm streptococcal antibodies in the blood
To determine the oxygen level found in the blood
To determine the underlying cause of their cyanosis
To determine the underlying cause of their cyanosis
Which education would the nurse provide the parent of an infant about how to treat a hypercyanotic spell following a crying episode?
Hold the infant in the knee-chest position
Place the infant in a semi-Fowler position
Administer oral fluids to prevent dehydration
Breastfeed the infant after they have calmed
Hold the infant in the knee-chest position
The nurse would teach the parent to Flex the hips and knees, as this decreases venous return to the heart from the legs. When venous return to the heart is decreased, the cardiac workload is decreased. Placing the child in a semi-Fowler position will not help to decrease the cardiac overload. Oral fluids are not administered to the child as this is will not relieve cyanosis. The child may not be able to feed orally, so the nurse would not advise breastfeeding the child.
Which recommendation would the nurse provide the parent of an unrepaired cardiac defect about managing the illness at home?
Highlight the need to be extremely concerned about cyanotic spells
Advise the parent relax discipline and limit-setting to prevent crying
Emphasize promoting normalcy within the limits of the child’s condition
Stress the importance of reduced caloric intake to decrease cardiac demands
Emphasize promoting normalcy within the limits of the child’s condition
Which complication is associated with the use of peripheral venous catheters?
Phlebitis
Cardiac dysfunction
Hirschsprung disease
Oxygen-induced carbon dioxide narcosis
Phlebitis
Which cause may account for a sudden increase in heart rate in a postoperative infant?
Vagal stimulation
Decreased perfusion
Respiratory distress (late)
Increased intracranial pressure
Decreased perfusion
Which action would the nurse take upon finding that the pulse distal to the cardiac catheter insertion site is weaker?
Elevate the affected extremity
Document findings in patient chart
Notify the provider of the abnormal finding
Apply warm compresses to the insertion site
Document findings in patient chart
Cerebral palsy may result from a variety of causes. It is now known that which is the most common cause of cerebral palsy?
Birth asphyxia
Neonatal diseases
Cerebral trauma
Prenatal brain abnormalities
Prenatal brain abnormalities
Which response from the child with cerebral palsy indicates to the nurse that the child is in pain?
Crying
Moaning
Telling the nurse to stop
Showing the nurse where the pain is
Moaning
Which statement describes the major goal of therapy for children with cerebral palsy?
Reverse degenerative processes that have occurred.
Cure the underlying defect causing the disorder.
Prevent spread to individuals in close contact with the child.
Recognize the disorder early and promote optimal development.
Recognize the disorder early and promote optimal development.
Which is a preferred medication or treatment to prevent cerebral edema in a comatose child?
Sedatives
Osmotherapy
Corticosteroids
Barbiturates
Osmotherapy
Which body function can be inferred from observing the balance and coordination status of a child?
Joint function
Bone function
Cerebral function
Cerebellar function
Cerebellar function
The nurse is doing a neurologic assessment on a 2-month-old infant following a car accident. Moro, tonic neck, and withdrawal reflexes are present. Which would the nurse recognize that these reflexes suggest?
Neurologic health
Severe brain damage
Decorticate posturing
Decerebrate posturing
Neurologic health
The nurse is caring for a 5-year-old child who had a craniotomy. The nurse is assessing the neurologic status of the child and has checked the level of consciousness, pupillary activity, and reflexes. Which additional item would the nurse assess in the patient?
Blood pressure
Motor function
Rectal temperature
Head circumference
Motor function
The nurse is caring for a 10-year-old child with a history of diabetes mellitus who recently had brain surgery. On assessment, the nurse finds that the body temperature has risen to 103°F. Which is an appropriate interpretation by the nurse?
Children with diabetes mellitus usually develop an infection after surgery.
High body temperature is common in children after surgical procedures.
Cerebral edema after brain surgery exerts pressure on the hypothalamus.
Excessive viscid secretions result in inadequate respiratory ventilation.
Cerebral edema after brain surgery exerts pressure on the hypothalamus.