Correct Answer: B

Rationale: The normal range of vital signs for pediatric patients varies with age. For 11 to 14-year-olds, the normal vital sign ranges are: Heart rate: 60-105 BPM; Respiratory rate: 12-20 RPM; Blood pressure: Systolic 85-120 mmHg, Diastolic 55-80 mmHg. The 13-year-old female in choice B has a diastolic blood pressure below the normal range, indicating hypotension. Additionally, her heart rate is at the upper limit of normal, and her respiratory rate is within normal limits. Choices A, C, and D all fall within the normal ranges for vital signs in pediatric patients.

Correct Answer: C

Rationale: In a child newly diagnosed with cystic fibrosis (CF), noisy respirations and a dry, non-productive cough are typically the first respiratory signs to appear. The other options, including a positive sweat test, bulky greasy stools, and meconium ileus, are among the earliest findings of CF. CF is a genetic condition that affects the production of mucus, sweat, saliva, and digestive juices. Due to a defective gene, these secretions become thick and sticky instead of thin and slippery, leading to blockages in various passageways, especially in the pancreas and lungs. Respiratory failure is a severe consequence of CF, making it crucial to monitor respiratory symptoms closely in affected individuals. Therefore, a moist, productive cough would not be an expected finding in a newly diagnosed child with CF.

Correct Answer: A

Rationale: The first action the nurse should take after assessing Mr. B is to administer oxygen and assist him to sit in the semi-Fowler's position. Administering oxygen helps improve tissue oxygenation, while sitting up in a semi-Fowler's position aids in better breathing and secretion clearance. Placing the client in a negative-pressure room is not the immediate priority unless isolation is needed. Performing a bronchoscopy or contacting the physician for antifungal medications is not the initial step in managing a client with suspected pneumonia.

Correct Answer: C

Rationale: Petechiae on the soft palate are not a typical finding in scarlet fever. Scarlet fever is caused by group A Streptococcus bacteria, often presenting with a strawberry tongue, red and swollen pharynx, and a sandpaper-like rash. The presence of petechiae on the soft palate is more commonly associated with conditions like rubella rather than scarlet fever. Therefore, this description is not correct in the context of scarlet fever.

Correct Answer: C

Rationale: A rapidly enlarging abdominal aortic aneurysm is at significant risk of rupture, which can be life-threatening. The standard treatment for a rapidly enlarging abdominal aortic aneurysm is surgical intervention to prevent rupture. Therefore, the appropriate action for the nurse to expect is that the patient will be admitted to the surgical unit, and resection will be scheduled. Observation and medication (Choice A) are not sufficient for a rapidly enlarging aneurysm, and sclerotherapy (Choice B) is not typically used for aortic aneurysms. Discharging the patient home (Choice D) would be inappropriate and dangerous given the risk of rupture.