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During a lumbar puncture procedure for confirmation of bacterial meningitis, the nurse notes that the infant's spinal fluid is cloudy. The nurse recalls this information indicates which result?

increased white blood cell (WBC) count

Which plant, if ingested by a toddler, would necessitate further action by the nurse?

lily

When assessing a client's vision, the nurse observes the client has difficulty seeing objects that are far away. Which condition would the nurse suspect the client is experiencing?

myopia

Which assessment finding in a client signifies a mild form of hypocalcemia?

numbness around the mouth

Which assessment technique would the nurse use to test a clients trigeminal nerve function?

ocular muscle movement

Which sign or symptom would be concerning for fluid volume excess in a child with a diagnosis of acute poststreptococcal glomerulonephritis?

periorbital edema?

Which clinical manifestation would be expected in a client with hyposecretion of growth hormone?

reduced bone density?

After percussing a client's posterior chest and hearing low-pitched hollow sounds over the whole chest, which term would the nurse use to document the finding?

resonance

During the neurological assessment of a client with a tentative diagnosis of Guillain-Barre syndrome, which clinical finding would the nurse expect the client to manifest?

increased muscular weakness

Which finding from cerebral spinal fluid would lead the nurse to suspect bacterial meningitis?

increased protein

Which finding for a client with a head injury indicates increasing intracranial pressure?

increased restlessness

A client reports pain in the posterior leg while walking and running. Which condition would the nurse suspect?

Achilles tendonitis

Which laboratory test will be elevated in a client with inflammatory arthritis?

Erythrocyte sedimentation rate (ESR)

Which condition is consistent with a client's report if posterior leg pain while walking that worsens upon rest?

tendonitis

Which history statement would be expected when admitting a child with acute glomerulonephritis to the inpatient unit?

the child had a sore throat a few weeks ago?

Which assessment would be the priority for the nurse to complete for the client who has Gullain-Barre syndrome with rapidly ascending paralysis?

assessing communication needs?

Which finding would the nurse observe in a child with autism spectrum disorder?

interest in music?

Hemoptysis is a clinical manifestation of which disease process?

pneumonia?

After auscultating the chest, how will the nurse document findings of bilateral, high-pitched, continuous whistling sounds heard during each expiration?

wheezes?

During a newborn assessment for developmental dysplasia of the hip, the nurse notes a clunk with the Ortolani test. Which statement by the nurse accurately explains the finding to the child's mother?

"it is the drooping of the hip on one side of the body" ?

The parents of a child with acute poststreptococcal glomerulonephritis ask the nurse why their child is being weighed every morning. Which response by the nurse is best?

"it provides a measure of how much protein is being lost" ?

When assessing a child for an intestinal infestation of pinworm, which instruction would the nurse give the parents?

"perform an anal cellophane tape test early in the morning"

A client reports unexplained weight gain and back pain from compression fracture of the vertebrae. On assessment, the nurse notes truncal obesity with excessively thin extremities, a moon-shaped face, a buffalo hump, thin hair, and adult acne. Which disease process would the nurse anticipate incorporating into the plan of care?

Cushing disease

Which finding would the nurse score a 3 for motor response on the Glasgow Coma Scale?

Flexion withdrawal?

The nurse in the emergency department is caring for a 9 year old child with a suspected spinal cord injury sustained while falling off a bicycle. Which initial action should the nurse take?

immobilizing the child's spine to limit additional injury

During which situation would the nurse expect the client who has rheumatoid arthritis to experience the most joint pain and stiffness?

in the morning on awakening?

Which clinical finding of an 8 year old child with a history of asthma requires immediate intervention?

audible wheezing

Which common response would the nurse monitor for in a client who has recently been extubated in the post anesthesia care unit after surgery?

bradycardia?

An adolescent with Duchenne muscular dystrophy has received care at the pediatric clinic since early childhood. On which body system would the nurse perform a focused assessment to identify life-threatening complications as the child ages?

cardiopulmonary

The parents of a toddler report to the nurse that the family has been living in a very old building. The nurse would carefully assess the child for the irreversible effects of possible lead poisoning by focusing on which organ system?

central nervous system?

Which sign is an associated complication of chronic kidney disease for a client undergoing peritoneal dialysis?

cloudy return dialysate?

Which urine characteristic is consistent with a urinary tract infection?

cloudy?

Which skin condition would the nurse expect when performing a physical assessment on a client with a history of hypothyroidism?

dry

An adolescent male complains of painful urination and yellow-green mucosal discharge from the urethra without abdominal pain. Which condition would the nurse suspect?

epididymitis?

Which clinical finding is associated with strabismus?

frequent squinting

Which clinical manifestation would the nurse monitor for in the child diagnosed with lead toxicity associated with the hematologic system?

glycosuria

Which test is considered the most accurate in the evaluation of the effectiveness of diet and insulin therapy over time?

glycosylated hemoglobin

Which hormonal deficiency would increase a client's risk for fractures?

growth hormone

A client reports their lips feel thicker, and they have joint pain and coarse facial features. The nurse would suspect an excessive secretion of which hormone?

growth hormone?

The nurse is reviewing the laboratory report of an adolescent child with nephrotic syndrome. Which data would the nurse expect the analysis of the child's urine to reveal?

high protein level

A high school student arrives at the local blood drive center to donate blood for the first time and as the site is being prepared for needle insertion, the student becomes agitated and starts to hyperventilate. Which instruction would the nurse provide the student?

use a rapid deep-breathing pattern


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