Nokea
The nurse is assessing a client with suspected meningitis. Which finding requires immediate action?
- A. Nuchal rigidity
- B. Headache
- C. Photophobia
- D. Fever of 100.4°F (38°C)
Correct Answer: A
Rationale: Nuchal rigidity is a critical sign of meningitis, indicating meningeal irritation and requiring immediate medical intervention to prevent complications.
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Select the standardized 'hand off' change of shift reporting system that is accurately paired with its elements.
- A. SBAR: Symptoms, background, assessment and recommendations
- B. ISBAR: Interventions, symptoms, background, assessment and recommendations
- C. The Five Ps: The patient, plan, purpose, problems and precautions
- D. BATON: Background, assessment, timing, ownership and next plans
Correct Answer: C
Rationale: The Five Ps accurately describes a hand-off system with elements: patient, plan, purpose, problems, and precautions, used to ensure comprehensive communication during shift changes.
A nursing assistant is taking care of a child in the arm restraint shown below. To provide care for this child, what should the assistant do?
- A. Unpin the restraint and perform range-ofmotion exercises.
- B. Unwrap the restraint and bathe the arm using warm water
- C. Leave the restraint in its current position.
- D. Remove one tape at a time while bathing the child’s arm.
Correct Answer: C
Rationale: The restraint should remain in position. Removing the restraint or untaping the restraint will risk dislodging the I.V.
A 12-year-old boy is admitted due to depression and post-trauma response. Child Protective Services reports that the boy's father is now in jail for molesting him from ages 6 to 9. Given the typical reactions of incest victims, the nurse should assess the child for which behavior? Select all that apply.
- A. Sexualized play.
- B. Aggression.
- C. Isolation at home.
- D. Running away.
- E. Truancy.
Correct Answer: A, B, C, D, E
Rationale: Incest victims may exhibit sexualized play, aggression, isolation, running away, and truancy as coping mechanisms or trauma responses.
You are going to perform gastric lavage for your adult client who was accidentally poisoned. How many mLs of irrigating solution would you instill after each suctioning?
- A. 100 mLs
- B. 250 mLs
- C. 400 mLs
- D. 500 mLs
Correct Answer: B
Rationale: Gastric lavage typically involves instilling 200-300 mL of solution (commonly 250 mL) per cycle to effectively wash out the stomach contents.
While assessing a neonate at 4 hours after birth, the nurse observes an indentation with a small tuft of hair at the base of the neonate's spine. The nurse should document this finding as which of the following?
- A. Spina bifida cystica.
- B. Spina bifida occulta.
- C. Meningocele.
- D. Myelomeningocele.
Correct Answer: B
Rationale: An indentation with a tuft of hair suggests spina bifida occulta, a mild defect without protrusion of spinal contents.