An infant is brought to the emergency department with suspected coarctation of the aorta. Which clinical symptoms would the nurse expect to find?
Cyanosis of the lips and tongue
Weak or absent femoral pulses
Bounding pulses in the upper extremities
High blood pressure in the lower extremities
Poor feeding and irritability
Correct Answer : B,C,E
A. Cyanosis of the lips and tongue is not a typical finding in coarctation of the aorta; rather, it is more associated with cyanotic congenital heart defects.
B. Weak or absent femoral pulses are expected due to reduced blood flow to the lower body, as the coarctation typically occurs distal to the left subclavian artery.
C. Bounding pulses in the upper extremities are common because the blood flow to the upper body is increased, leading to stronger pulses.
D. High blood pressure in the lower extremities is not typical; instead, there is often lower blood pressure in the lower body due to the obstruction.
E. Poor feeding and irritability are common symptoms in infants with heart conditions, as they may be in distress or not getting enough blood flow to meet their metabolic needs.
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Correct Answer is ["A","E","F"]
Explanation
A. Providing privacy during personal care and procedures is essential for adolescents, as it helps them feel more secure and respected during a vulnerable time.
B. This option is incorrect; discussing changes related to puberty can help the adolescent understand their body and promote healthy coping mechanisms.
C. Treating the adolescent as if they are not competent undermines their autonomy and can negatively impact their self-esteem; adolescents should be involved in their care and decision-making when appropriate.
D. Disregarding confidentiality can lead to a breakdown of trust; it is important to respect the adolescent's privacy while also keeping parents informed within appropriate limits.
E. Showing respect for the client's feelings and concerns helps validate their experiences and fosters a supportive environment during a challenging time.
F. Listening carefully to the client’s thoughts and concerns encourages open communication, allowing the nurse to address any worries and support the adolescent’s emotional needs.
Correct Answer is ["A","B","E"]
Explanation
A. Increased risk-taking behaviors are common as adolescents may feel invulnerable and engage in dangerous activities without considering the consequences.
B. Greater incidence of accidental injuries is often a result of risk-taking behaviors, which can be influenced by feelings of invulnerability.
C. Reduced mental health issues is incorrect as feelings of invulnerability can lead to increased stress and anxiety, negatively impacting mental health.
D. Improved social relationships are not guaranteed; feelings of invulnerability may actually lead to conflict or isolation if risk-taking behaviors are harmful.
E. Higher likelihood of substance abuse can result from a belief in invulnerability, leading adolescents to underestimate the risks associated with drug and alcohol use.
F. Enhanced academic performance is not directly linked to feelings of invulnerability and may suffer due to distractions from risky behaviors.