A nurse is assessing a young child and suspects coarctation of the aorta based on which finding?
Diastolic murmur.
Hypotension.
Excessive crying.
Unequal upper and lower extremity pulses.
The Correct Answer is D
Choice A rationale
A diastolic murmur is not a typical finding in coarctation of the aorta. This condition is more commonly associated with systolic murmurs.
Choice B rationale
Hypotension is not a common finding in coarctation of the aorta. In fact, hypertension in the upper extremities is more typical due to the narrowing of the aorta.
Choice C rationale
Excessive crying is not a specific indicator of coarctation of the aorta. It can be a symptom of many different conditions and is not diagnostic.
Choice D rationale
Unequal upper and lower extremity pulses are a key finding in coarctation of the aorta. The narrowing of the aorta causes reduced blood flow to the lower extremities, resulting in weaker pulses compared to the upper extremities.
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Correct Answer is A
Explanation
Choice A rationale
Shaking the inhaler for 3 to 5 seconds ensures that the medication is properly mixed and ready for administration. This step is crucial for delivering the correct dose of medication.
Choice B rationale
Pressing down twice on the MDI canister is incorrect as it can lead to an overdose of medication. The correct technique involves pressing down once per inhalation.
Choice C rationale
Waiting 2 minutes between inhalations is not necessary. The recommended wait time between inhalations is usually 30 seconds to 1 minute.
Choice D rationale
Rinsing the mouth with mouthwash after inhaling the medication is not recommended. Instead, rinsing with water is advised to prevent oral thrush, especially when using corticosteroid inhalers.
Correct Answer is A
Explanation
Choice A rationale
Increased crying episodes are a common indicator of pain in infants. Crying is a behavioral response to discomfort and can be more intense or frequent when the infant is in pain. This response is due to the activation of the infant’s nervous system, which signals distress through crying.
Choice B rationale
Decreased respiratory rate is not typically associated with pain in infants. Pain usually causes an increase in respiratory rate due to the body’s stress response, which involves the release of adrenaline and other stress hormones that stimulate the respiratory system.
Choice C rationale
Decreased heart rate is also not a common sign of pain in infants. Pain generally leads to an increased heart rate as part of the body’s fight-or-flight response, which is mediated by the sympathetic nervous system.
Choice D rationale
Increased formula consumption is not an indicator of pain. In fact, pain might reduce an infant’s appetite and lead to decreased feeding. Pain can cause discomfort during feeding, leading to fussiness and refusal to eat.