Nokea
History and Physical
6-year-old child
Vomited 3 times in the past 24 hr
Irritable behavior for the past 24 hr
Respiratory infection started 3 days ago
Brudzinski's and Kernig's signs positive
Nurse is planning care for a child during admission to the facility. Which action should the nurse take first?
- A. Obtain a prescription for pain medication.
- B. Collect blood cultures
- C. Transport the child to obtain a CT scan.
- D. Initiate seizure precautions.
Correct Answer: D
Rationale: Positive Brudzinski's and Kernig's signs indicate meningitis, making seizure precautions the priority to prevent complications.
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A nurse is caring for a client who has pneumonia and tells the nurse, “I feel like an elephant is sitting on my chest.†The client is weak and unable to walk.
After the nurse indicates chest pain protocol, which of the following is the priority diagnostic test?
- A. PT and INR
- B. 12 lead ECG
- C. Chest X-ray
- D. D-dimer test
Correct Answer: C
Rationale: The correct answer is C: Chest X-ray. When a patient presents with chest pain, a chest X-ray is crucial to evaluate for any acute cardiopulmonary conditions like pneumonia, pneumothorax, or aortic dissection. It helps identify any immediate life-threatening issues that require prompt intervention. PT and INR (A) are coagulation tests not typically indicated for acute chest pain. A 12-lead ECG (B) is important but usually done after the chest X-ray to assess for cardiac abnormalities. D-dimer test (D) is used to rule out pulmonary embolism, but it is not the priority test in the initial evaluation of chest pain.
Admission Assessment
Client reports new onset of fever and discomfort in their joints and increase malaise. No relevant
medical history. Client is alert to person, place, time, and situation. Reports generalized pain as 4
on a scale of 0 to 10. Macular rash present on cheeks bilateral. Lungs clear anterior and posterior.
Bowel sounds active in all 4 quadrants. Last bowel movement 1 day ago. Skin warm, dry, and
intact. Capillary refill less than 3 seconds. A 20-gauge IV saline lock inserted in back left hand
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing.
- A. Ensure that client has intake of at least 200mL/hr
- B. Initiate contact precautions
- C. Prepare client for light therapy
- D. Sickle cell crisis
- E. Psoriasis
- F. Osteomyelitis
Correct Answer: B,C
Rationale: Increased fluid intake and contact precautions are essential for managing systemic lupus erythematosus.
A nurse is providing preoperative teaching to an older adult client who is scheduled for surgery.
Which of the following actions should the nurse take to promote learning?
- A. Speak loudly when addressing the client
- B. Connect new information with the client's past experiences
- C. Present the information to the client using abstract concepts
- D. Use a 12 point font when printing written material for the client
Correct Answer: B
Rationale: The correct answer is B: Connect new information with the client's past experiences. This promotes learning by linking new concepts to existing knowledge, aiding in retention and understanding. Speaking loudly (A) may not enhance learning and can be off-putting. Presenting information abstractly (C) may confuse the client. Using a 12 point font (D) is a formatting preference and does not directly impact learning.
A nurse is reading a tuberculin skin test for a client who received a protein derivative test 72 hours ago.
Which of the following findings indicate a positive test?
- A. An induration measuring 10 mm
- B. A reddened area with no induration
- C. An induration measuring 3 mm
- D. A blister at the injection site
Correct Answer: A
Rationale: The correct answer is A because an induration measuring 10 mm is considered positive for a tuberculin skin test, indicating exposure to tuberculosis. A larger induration size suggests a stronger immune response. Choice B, a reddened area with no induration, is not specific for a positive test. Choice C, an induration measuring 3 mm, is below the threshold for positivity. Choice D, a blister at the injection site, is a sign of irritation rather than a positive test result.
A hospice nurse is visiting with the son of a client who has terminal cancer. The son reports sleeping very little during the past week due to caring for his mother.
Which of the following responses should the nurse make?
- A. I can give you information about respite care if you are interested.
- B. You should try to sleep more so you can take better care of your mother.
- C. Caring for a loved one at the end of life is very rewarding.
- D. It's important to stay strong for your mother during this time.
Correct Answer: A
Rationale: The correct answer is A because it acknowledges the caregiver's potential interest in respite care, which can provide them with much-needed rest and support. This response shows empathy and offers a helpful solution. Choice B is incorrect as it oversimplifies the situation and places undue pressure on the caregiver. Choice C is incorrect as it may invalidate the caregiver's struggles and emotions, as caregiving can be overwhelming and challenging. Choice D is incorrect as it emphasizes the importance of strength without addressing the caregiver's need for support and self-care.