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The nurse in the emergency department is triaging a group of clients. It would be a priority for the nurse to follow up with the child
- A. reporting increased urinary frequency and pain during urination.
- B. diagnosed with leukemia who has petechiae on their torso.
- C. diagnosed with acute epiglottitis two days ago and is drooling.
- D. with otitis media who has a temperature of 101.1°F (38.4°C) and is crying.
Correct Answer: C
Rationale: Drooling in a child with acute epiglottitis (C) suggests airway obstruction, a life-threatening emergency requiring immediate follow-up. Urinary symptoms (A), petechiae in leukemia (B), and otitis media (D) are less urgent, though concerning.
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The nurse is caring for assigned clients. The nurse should initially follow up on the client who
- A. has a basilar skull fracture and has bruises under their eyes.
- B. had a craniotomy and has a change in the Glasgow coma scale (GCS) from 13 to 11 in the last hour.
- C. has amyotrophic lateral sclerosis (ALS) and is requesting to have resuscitation efforts withheld.
- D. has Guillain-Barré syndrome (GBS) and is reporting lower extremity muscle weakness.
Correct Answer: B
Rationale: A GCS drop from 13 to 11 post-craniotomy (B) indicates neurological deterioration, possibly from hematoma, requiring immediate follow-up. Bruises with skull fracture (A), ALS DNR request (C), and GBS weakness (D) are less urgent, though GBS needs monitoring.
The nurse is caring for assigned clients in the mental health unit. The nurse should initially follow up on the client who
- A. is admitted for psychosis and is pacing in the hallway, mumbling to themselves.
- B. is being treated for obsessive compulsive disorder and has increased the number of times they wash their hands.
- C. has a substance use disorder and refuses to attend group therapy for the second time.
- D. is diagnosed with borderline personality disorder and is insisting on seeing the charge nurse for an allegation of abuse two days ago.
Correct Answer: A
Rationale: Pacing and mumbling in psychosis (A) suggest agitation or worsening symptoms, posing a safety risk requiring immediate follow-up. Increased hand washing (B), therapy refusal (C), and abuse allegations (D) are less urgent, as they are chronic or procedural.
The nurse in the emergency department (ED) is caring for a client experiencing septic shock. The nurse should prioritize
- A. obtaining an order to insert an indwelling urethral catheter.
- B. monitoring the client's serum white blood cell count and lactic acid.
- C. establishing frequent blood pressure monitoring.
- D. monitoring the client's capillary blood glucose.
Correct Answer: C
Rationale: Frequent BP monitoring (C) is the priority in septic shock to assess hemodynamic stability and guide fluid/vasopressor therapy, per Surviving Sepsis guidelines. Catheter insertion (A), lab monitoring (B), and glucose checks (D) are secondary to immediate circulatory assessment.
A medication error has occurred in the medical ward. After a thorough investigation was performed, the nurse manager posts a memorandum regarding changes in medication administration to be implemented immediately. The nurses on the unit recognized this management style as:
- A. Autocratic
- B. Democratic
- C. Participative
- D. Laissez-faire
Correct Answer: A
Rationale: Posting a memorandum with immediate changes (A) reflects an autocratic management style, where the manager makes decisions unilaterally. Democratic (B) and participative (C) involve staff input, while laissez-faire (D) lacks direction.
The nurse is providing the client with information regarding advanced directives. The nurse understands that giving this information supports the client's
- A. right to privacy.
- B. right to emergency care regardless of the ability to pay.
- C. C. self-determination.
- D. D. ability to receive appropriate treatment for their pain.
Correct Answer: C
Rationale: Advance directive discussions support self-determination (C) by empowering clients to make healthcare decisions. Privacy (A), emergency care (B), and pain treatment (D) are not directly related to advance directives.