Nokea
The nurse is reviewing a client's list of medications who has cystic fibrosis. The nurse anticipates a prescription for which medication?
- A. Multivitamin
- B. Aspirin
- C. Warfarin
- D. Simvastatin
- E. Salmeterol
Correct Answer: A, E
Rationale: Multivitamins address malabsorption, and salmeterol helps manage airway obstruction in cystic fibrosis.
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The nurse assists a client with cystic fibrosis in picking out items on a menu. It will indicate effective teaching if the client selects meals that are
- A. high in fat
- B. low in sodium
- C. low in calories
- D. low in protein
Correct Answer: A
Rationale: High-fat meals provide necessary calories for cystic fibrosis patients with high energy needs.
The nurse in the emergency department (ED) is caring for a 10-year-old client.
Item 5 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.
Orders
• laboratory tests: IgM and IgG antibodies
• doxycycline 100 mg capsule p.o. twice daily for fourteen days
• discharge client home
• follow-up with a primary care physician in two weeks
The nurse reviews and executes the physician's orders. Which of the following actions should the nurse take when performing venipuncture on a 10-year-old client?
- A. Identify the child by only checking their identification armband.
- B. Apply a cold compress to the area to promote vasodilation.
- C. Demonstrate the procedure using a stuffed animal.
- D. Allow the child to decide which arm they would like for the venipuncture.
- E. Ask the child if they want to help set up some equipment.
- F. Offer the child a sedative to help them relax before the procedure.
Correct Answer: C, D, E
Rationale: Demonstrating on a stuffed animal, allowing arm choice, and involving the child in setup reduce anxiety and promote cooperation. Cold compresses constrict vessels, and sedatives are not routinely offered.
The nurse is caring for assigned clients and is reviewing laboratory data. Which laboratory data requires follow-up? A client with a
- A. serum total cholesterol 180 mg/dl (4.65 mmol/L)
- B. glycosylated hemoglobin (A1C) 7.5%
- C. serum calcium 9.2 mg/dl (2.30 mmol/L)
- D. serum creatinine 1.0 mg/dL (88.4 µmol/L)
Correct Answer: B
Rationale: An A1C of 7.5% is elevated for a client with diabetes mellitus (DM), as the target is typically ≤7%. This requires follow-up to assess glycemic control.
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.
The following scenario applies to the next 5 items
The nurse in the emergency department (ED) is caring for a 10-year-old client.
Item 1 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.
Which of the following would require immediate follow-up?
- A. temperature and pulse oximetry reading
- B. pulse, respirations, and blood pressure
- C. medical and surgical history
- D. integumentary assessment findings
- E. lymph node assessment
- F. recent camping trip
- G. immunization status
Correct Answer: D, E, F
Rationale: The bullseye rash, inguinal lymphadenopathy, and recent camping trip suggest Lyme disease, requiring immediate follow-up.