Nokea
A 6-year-old child is alert but quiet when brought to the emergency center with periorbital ecchymosis and ecchymosis behind the ears. The nurse suspects potential child abuse and continues to assess the child for additional manifestations of a basilar skull fracture. What assessment finding would be consistent with the basilar skull fracture?
- A. Blurred vision.
- B. Shoulder pain.
- C. Abdominal pain.
- D. Rhinorrhea or otorrhea with halo sign.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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The nurse is caring for a client with diabetic ketoacidosis (DKA). Which laboratory result requires immediate intervention?
- A. Blood glucose of 250 mg/dL.
- B. Serum potassium of 3.5 mEq/L.
- C. Serum sodium of 135 mEq/L.
- D. Arterial blood pH of 7.30.
Correct Answer: D
Rationale: Corrected Rationale: An arterial blood pH of 7.30 indicates the client is in acidosis, which is a life-threatening condition in DKA. Immediate intervention is required to correct the acidosis and prevent further complications such as organ failure or coma. Blood glucose of 250 mg/dL is elevated but not an immediate threat to life in comparison to acidosis. Serum potassium of 3.5 mEq/L and serum sodium of 135 mEq/L are within normal ranges and do not warrant immediate intervention in the context of DKA.
The nurse is preparing to administer an oral medication to a client with dysphagia. Which action should the nurse take?
- A. Crush the medication and mix it with applesauce.
- B. Have the client drink a full glass of water with the medication.
- C. Administer the medication with a small amount of pudding.
- D. Place the medication at the back of the client's tongue.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The healthcare provider is assessing a client with chronic obstructive pulmonary disease (COPD). Which finding requires immediate intervention?
- A. Oxygen saturation of 88%.
- B. Use of accessory muscles for breathing.
- C. Respiratory rate of 26 breaths per minute.
- D. Barrel-shaped chest.
Correct Answer: C
Rationale: A respiratory rate of 26 breaths per minute is an abnormal finding and indicates that the client is experiencing respiratory distress, requiring immediate intervention. This rapid respiratory rate can signify inadequate oxygenation and ventilation. Oxygen saturation of 88% is low but not as immediately concerning as a high respiratory rate, which indicates the body is compensating for respiratory distress. The use of accessory muscles for breathing and a barrel-shaped chest are typical findings in clients with COPD but do not indicate an immediate need for intervention as they are more chronic in nature and may be seen in stable COPD patients.
The nurse is planning a community health fair to promote mental health awareness. Which activity is most likely to engage participants?
- A. a lecture on the signs and symptoms of depression
- B. a workshop on stress management techniques
- C. a panel discussion with mental health experts
- D. a booth distributing brochures on mental health resources
Correct Answer: B
Rationale: A workshop on stress management techniques is the most engaging activity as it allows participants to actively participate, learn practical skills, and interact with others. This hands-on approach fosters engagement and provides attendees with tools they can directly apply in their lives. Choice A, a lecture, may be informative but lacks the interactive element that promotes engagement. Choice C, a panel discussion, might be informative but could be passive for attendees. Choice D, distributing brochures, is informative but lacks the interactive and engaging nature of a workshop.
During a home visit, the nurse observes that an elderly client has a cluttered living environment and poor lighting. What should the nurse do first?
- A. suggest the client hires a cleaning service
- B. assist the client in organizing the living space
- C. assess the client's risk for falls
- D. provide the client with information on home safety
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.