the nurse is assessing a child with a possible fracture what would the nurse identify as the most reliable indicator the nurse is assessing a child with a possible fracture what would the nurse identify as the most reliable indicator
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Nursing Elites

HESI LPN

Pediatric Practice Exam HESI

1. When assessing a child with a possible fracture, what would be the most reliable indicator for the nurse to identify?

Correct answer: B

Rationale: Point tenderness is the most reliable indicator of a possible fracture in a child. It refers to localized pain at a specific point, indicating a potential bone injury. Lack of spontaneous movement (Choice A) is non-specific and can be due to various reasons. Bruising (Choice C) may be present in fractures but is not as specific as point tenderness. Inability to bear weight (Choice D) can also be seen in fractures but may not always be present, making it less reliable compared to point tenderness.

2. What is an early sign of congestive heart failure that the nurse should recognize?

Correct answer: A

Rationale: Tachypnea is an early sign of congestive heart failure that nurses should recognize. Tachypnea refers to rapid breathing, which can be an indication of the body's attempt to compensate for decreased cardiac output in congestive heart failure. Bradycardia (choice B) is a slow heart rate and is not typically associated with congestive heart failure. Inability to sweat (choice C) and increased urinary output (choice D) are not specific early signs of congestive heart failure and are not typically recognized as such.

3. A child with glomerulonephritis is admitted in the acute edematous phase. Based on this diagnosis, which nursing intervention should the PN plan to include in the child's plan of care?

Correct answer: C

Rationale: The correct answer is to measure blood pressure every 4 to 6 hours. In glomerulonephritis, monitoring blood pressure is crucial as hypertension is a common complication. This helps in assessing the child's condition and response to treatment. Choice A, recommending parents bring favorite snacks, is not related to managing glomerulonephritis. Choice B, encouraging ambulation daily to the playroom, may not be appropriate during the acute edematous phase when the child may be experiencing fluid overload. Choice D, offering a selection of fresh fruit for each meal, is not directly relevant to managing the complications of glomerulonephritis.

4. A client is prescribed verapamil for hypertension. The nurse should monitor the client for which common adverse effect?

Correct answer: A

Rationale: Verapamil, a calcium channel blocker commonly used for hypertension, is known to cause constipation as a frequent adverse effect. This occurs due to its effects on smooth muscle relaxation in the gastrointestinal tract, leading to decreased motility. Headache, muscle cramping, and fatigue are not typically associated with verapamil use and are less common side effects. Therefore, the nurse should closely monitor the client for symptoms of constipation when administering verapamil.

5. A healthcare professional is preparing to perform denture care for a client. Which of the following actions should the professional plan to take?

Correct answer: B

Rationale: The correct answer is to brush the dentures with a toothbrush and denture cleaner. This action ensures effective cleaning of the dentures. Dentures should be rinsed with cool or lukewarm water, not hot water, to prevent damage. Placing the dentures in a clean, dry storage container is not the immediate next step after cleaning; they should be kept moist to prevent warping.

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