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Questions 148

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Question 1 of 5

The nurse is caring for a client admitted with multiple trauma. Fractures include the pelvis, femur, and ulna. Which finding should be reported to the physician immediately?

Correct Answer: A

Rationale: Hematuria in a client with pelvic and femur fractures suggests possible urinary tract or bladder injury, requiring immediate reporting.

Question 2 of 5

The physician has made a diagnosis of 'shaken child' syndrome for a 13-month-old who was brought to the emergency room after a reported fall from his highchair. Which finding supports the diagnosis of 'shaken child' syndrome?

Correct Answer: C

Rationale: Retinal hemorrhages are a hallmark of shaken baby syndrome due to the shearing forces from violent shaking causing bleeding in the retina.

Question 3 of 5

A child with Down syndrome has a developmental age of 4 years. According to the Denver Developmental Assessment, the 4-year-old should be able to:

Correct Answer: B

Rationale: Per the Denver Developmental Screening Test, a 4-year-old should be able to give their first and last name, a milestone achievable despite developmental delays.

Question 4 of 5

A client has experienced 48 hours of severe repeated bouts of vomiting. Which acid-base imbalance is of most concern?

Correct Answer: D

Rationale: Severe vomiting causes loss of gastric acid, leading to metabolic alkalosis (
D). Respiratory imbalances (A,
B) and metabolic acidosis (
C) are less likely.

Question 5 of 5

The nurse is caring for an infant following a cleft lip repair. While comforting the infant, the nurse should avoid:

Correct Answer: B

Rationale: Offering a pacifier is contraindicated after cleft lip repair as it can disrupt the surgical site and impair healing.

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