Nokea
The nurse is assessing a patient for lead poisoning. Which patient is the nurse most likely assessing?
- A. Young infant
- B. Toddler
- C. Preschooler
- D. Adolescent
Correct Answer: B
Rationale: The correct answer is B: Toddler. Toddlers are at highest risk for lead poisoning due to their habit of putting objects in their mouths. Lead exposure can come from old paint, soil, or water. Young infants have less exposure due to limited mobility. Preschoolers are less at risk as they are less likely to engage in mouthing behaviors. Adolescents have lower risk as they are less likely to come into contact with lead sources.
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A patient has an ankle restraint applied. Upon assessment
- A. the nurse finds the toes a light blue color. Which action will the nurse take next?
- B. Remove the restraint.
- C. Place a blanket over the feet.
- D. Do a complete head-to-toe neurologic assessment.
- E. Take the patient's vital signs.
Correct Answer: A
Rationale: The correct answer is A because a light blue color in the toes indicates poor circulation due to the restraint. The nurse should assess for tissue damage and remove the restraint immediately to restore circulation. Removing the restraint is the priority to prevent further complications. Choice B is incorrect as it doesn't address the circulatory issue. Choices C, D, and E are not the immediate concern and can be addressed after addressing the circulation problem.
The nurse is presenting an educational session on safety for parents of adolescents. Which information will the nurse include in the teaching session?
- A. Increased aggressiveness and blood spots on clothing may indicate substance abuse.
- B. Increased aggressiveness is an environmental clue that may indicate an adolescent is abusing.
- C. Adolescents need information about the effects of uncoordination on accidents.
- D. Adolescents need to be reminded to use seat belts primarily on long trips.
Correct Answer: A
Rationale: The correct answer is A. Increased aggressiveness and blood spots on clothing are potential signs of substance abuse in adolescents. This is important information for parents to be aware of as it can indicate a serious issue that needs to be addressed promptly.
Choice B is incorrect because it only partially addresses the issue by mentioning aggressiveness but does not include the specific indication of blood spots on clothing related to substance abuse.
Choice C is incorrect as it focuses on uncoordination and accidents, which is not directly related to the signs of substance abuse mentioned in the question.
Choice D is incorrect as it discusses seat belt use, which is important but not the main focus of the educational session on safety for parents of adolescents.
In summary, choice A is the correct answer because it provides crucial information about potential signs of substance abuse in adolescents, which is relevant to the safety concerns of parents.
The nurse is performing the 'Timed Get Up and Go (TUG)' assessment. Which actions will the nurse take? (Select all that apply.)
- A. Ranks a patient as high risk for falls after patient takes 18 seconds to complete.
- B. Teaches patient to rise from a straight back chair using arms for support.
- C. Instructs the patient to walk 10 feet as quickly and safely as possible.
- D. Observes for unsteadiness in patient's gait.
- E. Begins counting after the instructions.
Correct Answer: C,D,F
Rationale: The correct answers are C, D, and F.
C: Instructing the patient to walk 10 feet quickly and safely is a key component of the TUG test to assess mobility and fall risk.
D: Observing for unsteadiness in the patient's gait is important to evaluate balance and stability during the test.
F: Beginning counting after giving instructions ensures an accurate timing of the patient's performance.
Incorrect choices:
A: Ranking a patient as high risk for falls after taking 18 seconds is not accurate as the cutoff time for increased fall risk is typically 12-14 seconds.
B: Teaching the patient to rise from a straight back chair using arms for support is not part of the TUG assessment and may not provide accurate information about the patient's mobility and fall risk.
A homeless adult patient presents to the emergency department. The nurse obtains the following vital signs: temperature 94.8° F, blood pressure 106/56, apical pulse 58, and respiratory rate 12. Which vital sign should the nurse address immediately?
- A. Respiratory rate
- B. Temperature
- C. Apical pulse
- D. Blood pressure
Correct Answer: B
Rationale: The nurse should address the temperature (Choice B) immediately because it is below the normal range (normal range is around 97-99°F). A low body temperature, such as 94.8°F, can indicate hypothermia, which is a medical emergency requiring prompt intervention to prevent complications like organ dysfunction or cardiac arrest. Addressing the temperature first is crucial to prevent further deterioration of the patient's condition.
Other choices are not as urgent:
A: Respiratory rate (12 breaths per minute) is within the normal range.
C: Apical pulse (58 beats per minute) is slightly lower but not immediately life-threatening.
D: Blood pressure (106/56 mmHg) is on the lower side but not acutely concerning.
The nurse is presenting an educational session on safety for parents of adolescents. Which information will the nurse include in the teaching session?
- A. Increased aggressiveness and blood spots on clothing may indicate substance abuse.
- B. Increased aggressiveness is an environmental clue that may indicate an adolescent is abusing.
- C. Adolescents need information about the effects of uncoordination on accidents.
- D. Adolescents need to be reminded to use seat belts primarily on long trips.
Correct Answer: A
Rationale: The correct answer is A because increased aggressiveness and blood spots on clothing are potential signs of substance abuse in adolescents. Aggressiveness and physical changes can indicate underlying issues like substance abuse, which is crucial for parents to recognize for intervention. B is incorrect because aggressiveness alone is not a definitive clue for substance abuse. C is incorrect as it focuses on uncoordination rather than specific signs of substance abuse. D is incorrect as it is a general safety reminder and not specific to substance abuse indicators.