Nokea
The nurse in the emergency department (ED) is caring for a 10-year-old client.
Item 3 of 5
Nurses' Notes
1322: 10-year-old client and his parents report an 8-day history of a brownish-raised lesion over the back of his left leg. The parents report that the size of the rash has increased. The parents report returning from a one-week camping trip three weeks ago. The parents deny efficacy with over-the-counter antihistamine creams. The client's parents deny that the child has had a fever but has felt 'warm' occasionally and endorsed an intermittent headache. They report an area of firmness in the child's groin. On assessment, there was an erythematous, raised, nonpainful, oval patch on the back of his left leg. This was an enlargement of an inguinal lymph node. The child is alert and fully oriented and denies any pain. Peripheral pulses palpable 2+. No cyanosis or edema in the extremities. Lung sounds clear bilaterally. The parents report that the child did not receive the seasonal influenza vaccine. He currently takes a multivitamin for iron deficiency anemia and was hospitalized one year ago for an appendectomy. The parents state that the child’s sibling had influenza one month ago. Vital signs: T 98.8°F (37.1°C); HR 78 beats/min; RR 16 breaths/min; BP 110/76 mm Hg. SpO2 97% on room air.
The client is demonstrating manifestations consistent with
- A. influenza
- B. Rocky Mountain spotted fever
- C. Lyme disease
- D. None of the above
Correct Answer: C
Rationale: The bullseye rash, lymphadenopathy, and camping history are consistent with Lyme disease.
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The nurse is demonstrating the appropriate use of a car seat to a client. The nurse is demonstrating which level of prevention?
- A. Primary
- B. Secondary
- C. Tertiary
- D. Quaternary
Correct Answer: A
Rationale: Car seat education prevents injury, a primary prevention strategy.
The nurse cares for a client immediately following a shoulder reduction procedure with moderate sedation. The nurse assesses the client as restless and irritable. The nurse should take which priority action?
- A. Assess the client for pain
- B. Assess the client's oxygen saturation
- C. Assess the client with the Glasgow Coma Scale (GCS)
- D. Assess the client's lung sounds
Correct Answer: B
Rationale: Restlessness and irritability post-sedation may indicate hypoxia. Assessing oxygen saturation is the priority to ensure airway and breathing stability.
The following scenario applies to the next 1 items
The nurse is caring for a 23-year-old male in the psychiatry clinic
Item 1 of 1
History and Physical
Chief Complaint – 23-year-old male presents with his mother, who insists, 'he needs some help; all he does is work and play video games and doesn't socialize with anyone.'
History of Present Illness – 23-year-old Caucasian male presents with his mother with reports of his asociality starting to impact his life. He reports that while in high school, he had a degree of anxiety about socializing with his peers. He thought that as the years passed, it would get better.
He states his anxiety has declined, but he gets paranoid around individuals because they may want to 'do him wrong.' He cannot point to an example of maleficence caused by his friends. He states he doesn't have a problem with his self-esteem, but sometimes social situations are avoided because 'I can see ahead into the future, and I want to avoid people who can bring me harm through their negative energy.' The client reports that he spends his time playing video games, stating he likes games that are fantasy related because 'they take me a while.' He states he has a strong interest in tarot card readings, and for his close friends, he does provide readings. He did offer the examiner a tarot card reading. His interest in tarot cards came from his self-described ability to interpret the spirits of individuals and their auras.
He states that occasionally, he will browse social media and identify a quote or lyric that he feels 'was directed towards me.' The client is employed as an overnight hotel clerk, and his highest level of education is a high school diploma. The client has never been married and has no children. His last relationship was seven years ago, which was brief. He identifies himself as heterosexual. He has a distant criminal history of petty theft and identity theft. No history of violent crimes. He has never been incarcerated. He denies drinking alcohol. However, he does smoke marijuana 2-3x a week. He lives in the basement with his Mother and declines to move out because he has no plans.
Medical History – No past medical history, no past psychiatric history. The client has never been hospitalized—no family history of psychiatric illness.
Mental Status Examination – Alert and fully oriented; Fair concentration; No psychomotor retardation or agitation; Cooperative behavior; Adequately groomed; unkept hair that is bright green in color. He has multiple facial piercings (nose, eyebrow, lip). Speech is at a normal rate with a slightly increased volume Affect is bright, and he describes his mood as 'okay.' Denies suicidal or homicidal ideations. Intact insight and judgment
Complete the sentence below by choosing from the list of options. The client is at highest risk of developing ___ as evidenced by the client's ___
- A. antisocial personality disorder
- B. bipolar disorder
- C. schizotypal personality disorder
- D. dependent personality disorder
- E. illogical thought content
- F. criminal history
- G. self-esteem
Correct Answer: C, E
Rationale: The client's paranoia, magical thinking (tarot cards, auras), and social avoidance suggest schizotypal personality disorder, evidenced by illogical thought content.
When the nurse is educating parents of young kids with congenital heart defects, it is essential to teach them about the early signs and symptoms of heart failure so that they can recognize it sooner. Which of the following should the nurse emphasize as early signs of heart failure?
- A. Diaphoresis
- B. Sudden weight gain
- C. No wet diapers
- D. Hypoxia
- E. Increased appetite
Correct Answer: A, B, C, D
Rationale: Diaphoresis, sudden weight gain, no wet diapers, and hypoxia are early signs of heart failure in children.
The following scenario applies to the next 1 items
The nurse in the emergency department (ED) is caring for a pregnant client.
Item 1 of 1
Nurses' Notes
Emergency Department
0735: Client reports sudden onset of nausea and vomiting, heavy vaginal bleeding with dark red blood, frequent low-intensity contractions, lower abdominal pain rated 9/10 on the Numerical Rating Scale for past two hours, and dull lower back pain rated 2/10 on the Numerical Rating Scale for the past 24 hours. Client is 30 weeks gestation (G=4 T=3 P=0 A=0 L=3) and is Rh-positive. Vital signs: T 99.8 ⁰ F (37.7 ⁰ C), P 99, RR 16, BP 112/76, pulse oximetry reading 94% on room air. Uterine tenderness present with gentle palpation. Client states they are a one-pack per day cigarette smoker and denies any alcohol or illicit drug use.
The nurse reviews the client's admission data to begin the plan of care. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two (2) actions the nurse should take to address that condition, and two (2) parameters the nurse should monitor to assess the client's progress.
- A. initiate electronic fetal monitoring (EFM), administer Rh immune globulin, assess for signs of hyperemesis gravidarum, start peripheral access device, perform an ultrasound examination
- B. placenta previa, preterm labor, placental abruption, preeclampsia
- C. continuous electronic fetal monitoring (EFM), 24-hour urine specimen, strict intake & output, vital signs, serum creatinine levels
Correct Answer: B (placental abruption), A (initiate EFM, start peripheral access device), C (fetal heart rate pattern, vital signs)
Rationale: The client's heavy vaginal bleeding, severe abdominal pain, and frequent contractions at 30 weeks suggest placental abruption. EFM and peripheral access are critical interventions, and monitoring fetal heart rate and vital signs assesses progress.