Nokea
The nurse is caring for a four-year-old child. While developing a plan of care, the nurse recognizes the child is in which stage of Erikson's stages of psychosocial development?
- A. Initiative vs. Guilt
- B. Autonomy vs. Shame and Doubt
- C. Industry vs. Inferiority
Correct Answer: A
Rationale: A four-year-old is in the Initiative vs. Guilt stage, focusing on exploring and taking initiative.
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The nurse in the emergency department (ED) is caring for a 10-year-old client.
Item 4 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.
Progress Notes
1401: The client was evaluated. The rash is localized, raised, and appears like a bullseye. The client has inguinal lymphadenopathy. The client's recent camping trip supports the probability of a vector-borne illness—specifically, Lyme disease.
The nurse reviews the physician's progress note and plans care for this client. For each potential intervention, click to specify whether the intervention is indicated or not indicated for the client.
- A. Obtain confirmatory testing via urine specimen
- B. Notify the local health department if confirmation testing comes back positive
- C. Request an order for antiviral medication
- D. Prepare the client for lumbar puncture
Correct Answer: B (indicated); A, C, D (not indicated)
Rationale: Notifying the health department is indicated for Lyme disease. Urine testing, antivirals, and lumbar puncture are not indicated for Lyme disease diagnosis or management.
The following scenario applies to the next 1 items
The nurse is caring for a client in active labor
Item 1 of 1
Nurses’ Note
23-year-old primipara at 39 gestational weeks was admitted for induction via oxytocin. Currently, she is 100% effaced and 10 cm dilated. An internal fetal spiral electrode and intrauterine pressure catheter were placed. Uterine contractions are now 2 to 2.5 minutes apart, 70 to 90 seconds in duration. The fetal heart tracing showed decreased fetal heart rate following uterine contraction. This pattern was present in more than 50% of the uterine contractions.
Medications
Oxytocin via continuous infusion
Complete the following sentence from the list of options. Based on the fetal heart rate tracing, the client is experiencing ___ that is caused by ___
- A. late decelerations
- B. early decelerations
- C. variable decelerations
- D. reduced blood flow to the placenta
- E. umbilical cord compression
- F. fetal head compression
Correct Answer: A, D
Rationale: Late decelerations, caused by reduced placental blood flow, indicate fetal hypoxia and require intervention.
The following scenario applies to the next 1 items
The nurse is caring for a 72-year-old client in the emergency department (ED)
Item 1 of 1
Nurses' Notes
1430: 72-year-old male was brought to the ED with reports of dyspnea, chest pain, diaphoresis, and restlessness. The client's daughter reports that he recently took a long drive across several states and that the symptoms started abruptly. The client's oxygen saturation was 80% on room air and improved to 86% on 100% FiO2 via a nonrebreather mask. The physician was immediately notified at this time of the client's condition and came to the bedside for evaluation.
1442: The physician ordered rapid sequence intubation medications for immediate endotracheal intubation (ETT). The physician intubated the client using a #8 ETT and connected the client to mechanical ventilation using assist-control at a tidal volume of 500 mL, rate of 12/minute, 100% FiO2, PEEP 5 cm H2O. Post-intubation vital signs: T 99° F (37° C), P110, RR 12, BP 90/62, pulse oximetry reading 98%.
The nurse has reviewed both of the Nurses' Note entries and is planning care for the client. For each potential nursing intervention, click to specify whether the intervention is indicated or contraindicated for the care of the client.
- A. Request an order for a chest radiograph (x-ray)
- B. Obtain an order for an arterial blood gas (ABG)
- C. Collaborate with respiratory therapy to assist in the client's care
- D. Place the client in low-Fowler's position
- E. Request an order to administer an 0.45% saline intravenous fluid bolus
- F. Turn the client every four hours
- G. Suction the endotracheal tube (ETT) every two hours
Correct Answer: A, B, C, F (indicated); D, E, G (contraindicated)
Rationale: Indicated: Chest x-ray confirms tube placement, ABG assesses ventilation, respiratory therapy collaboration optimizes care, and turning prevents complications. Contraindicated: Low-Fowler€™s position worsens respiratory distress, 0.45% saline is inadequate for hypovolemia, and routine ETT suctioning is unnecessary.
The following scenario applies to the next 1 items
The emergency department nurse is caring for a 22-year-old with altered mental status
Item 1 of 1
Admission Notes
2330 – 22-year-old male client arrived at the emergency department (ED) with friends who were at a party and was observed snorting a white powder and started acting erratically.
The client is hyper-alert, agitated, and only oriented to place on assessment. The client started shouting at staff during the assessment and struck a nurse with his fist. The primary healthcare provider (PHCP) was immediately notified of this incident.
Vital Signs
• Temperature 98.0o F (37o C)
• Pulse 110/minute
• Respirations 16/minute
• Blood Pressure 155/96 mm Hg
• O2 saturation 96% on room air
Complete the following sentences from the list of options.. Based on the client assessment, the client is likely intoxicated with ___ the nurse should immediately ___ based on the client's ___
- A. heroin
- B. cocaine
- C. restrain the client
- D. obtain a urine drug screen
- E. blood pressure
- F. physical violence
Correct Answer: B, C, F
Rationale: The client's agitation, hyper-alertness, and violence suggest cocaine intoxication. Immediate restraint ensures safety, and violence justifies this action.
The following scenario applies to the next 1 items
The nurse cares for a primigravida in labor.
Item 1 of 1
Nurses’ Note
1940: The client is alert and fully oriented. The client is talkative and has an anxious affect. Cervical dilation of 6 cm with 100% effacement. No vaginal discharge was noted. Contractions are noted every 2-3 minutes, lasting 40-60 seconds with moderate intensity.
Fetal Heart Rate
Continuous fetal heart monitoring (FHR): 130-145/minute with normal variability.
Vital Signs
• Oral Temperature 98o F (37o C)
• Heart rate 84/minute
• Respirations 20/minute
• Blood pressure 131/72 mm Hg
• Oxygen saturation 95% on room air
The nurse reviews the client's clinical data.
Drag a word from the choices below to complete the sentence.
Based on the clinical data, the client is in the ___ stage of labor. Specifically, the ___ phase.
- A. first
- B. second
- C. third
- D. fourth
- E. latent
- F. active
- G. transition
Correct Answer: A, F
Rationale: Cervical dilation of 6 cm with 100% effacement and frequent contractions indicate the first stage of labor, active phase.