Patient Data

Exhibits

The client continues to have stable neurologic assessments. The nurse provides interventions to promote client safety while in the hospital. Click to indicate which interventions promote client safety. Each column must have at least one response selected.

Initiate use of the bed alarm

Place all client belongings out of reach

Instruct the client to call before getting up

Provide a call button kept within reach

Place the client in a room near the elevator

Complete a swallow study before giving anything by mouth

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"A"}}

Rationale:

Initiate use of the bed alarm: This alerts staff when the client attempts to get out of bed, enabling quick assistance. It is especially crucial for clients with unilateral weakness and impaired mobility after stroke. Early response helps prevent falls and related injuries.
Place all client belongings out of reach: Placing items out of reach encourages the client to stretch, reach, or attempt to get out of bed unsafely. Stroke patients may have limited strength and poor balance, making this dangerous. It increases the risk of injury and delays access to essential items.
Instruct the client to call before getting up: Teaching the client to seek assistance before attempting to ambulate minimizes the risk of unassisted movement. Stroke patients often have impaired coordination or weakness, increasing the risk of falling.
Provide a call button kept within reach: Keeping the call bell within the client’s reach promotes autonomy and timely communication with the care team. It enables the client to signal for help easily in case of urgent needs or sudden symptoms.
Place the client in a room near the elevator: A room near the elevator may expose the client to high traffic, noise, and stimulation, which can increase confusion or anxiety. For a stroke patient needing rest and monitoring, this environment is not ideal.
Complete a swallow study before giving anything by mouth: A bedside swallow evaluation identifies risk for aspiration, which is common in stroke clients with impaired speech and facial droop. Preventing oral intake until clearance protects against aspiration pneumonia and choking.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is ["A","C","E"]

Explanation

Rationale:

A. Shaking that changes the child's handwriting legibility: Sudden onset of tremors affecting fine motor skills may indicate a neurological issue, such as a seizure disorder or early signs of a neurological condition, and requires prompt evaluation by the school nurse.

B. Bruises on both knees after the weekend: Bruises on the knees in children are often consistent with normal play and activity. Unless the bruises are unusual in pattern or location (e.g., upper arms, back), they typically do not require immediate referral.

C. Sunburn with blisters on the face, arms, and hands: Blistering sunburns can lead to dehydration, pain, and secondary infection. Facial involvement and blistering elevate the severity and warrant assessment and possible treatment recommendations.

D. Refuses to complete written homework assignments: While this behavior might suggest learning or behavioral challenges, it is not an urgent health issue requiring immediate referral. Teachers should monitor and possibly refer through academic support services, not directly to the nurse.

E. Thirst and frequent requests for bathroom breaks: These symptoms could be early signs of undiagnosed diabetes mellitus and warrant immediate attention from the school nurse to initiate further assessment and notify the child’s guardian.

A. 8. B. 10. C. 7. D. 9.

Correct Answer is A

Explanation

Rationale:

Heart rate: 120 bpm = 2

Respirations: 44/min with a loud cry = 2

Muscle tone: slight flexion with some resistance = 1

Reflex irritability: loud cry with stimulation = 2

Color: acrocyanosis (blue extremities) = 1

Total = 2 + 2 + 1 + 2 + 1 = 8

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Patient Data Exhibits The client continues to have stable neurologic assessments. The nurse provides interventions to promote client safety while in the hospital. Click to indicate which interventions promote client safety. Each column must have at least one response selected.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The school nurse is preparing a presentation for elementary school teachers to inform them when a child should be referred to the school clinic for further follow-up. The teachers should be instructed to report which situations to the school nurse? Select all that apply.

Correct Answer is ["A","C","E"]

Explanation

Correct Answer is A

Explanation

Four days after exposure to COVID-19 a client has a negative COVID-19 test result. Eight days after the negative test result, the client presents with fever, fatigue, and cough and the nurse performs a second COVID-19 test. Which action is most important for the nurse to take?

A client who has been taking colchicine calls the clinic with reports of an acute gout attack of the right great toe. The client has a history of kidney stones and esophageal reflux. Which finding warrants immediate intervention by the nurse?

A client with Neisseria meningitidis calls the nurses station to report a severe headache and vomiting. The unlicensed assistive personnel (UAP) approaches the room to provide an emesis basin and is stopped by the nurse. Which action should the nurse take?

The nurse is reviewing a pregnant client's prenatal immunization history. Which immunization should the nurse instruct the client to receive after pregnancy?

After diagnosis and initial treatment of a pre-school age child with cystic fibrosis, the nurse provides home care instructions to the parents. Which statement by the child's parents indicates that understanding of the home care treatment to promote pulmonary function?

A 6-week-old infant with pyloric stenosis is scheduled for a pyloromyotomy. Which pre-operative nursing action has highest priority?

Exhibits After two days of intensive care, the client is transferred to the telemetry floor. The floor nurse is preparing a plan of care for the client. Which modifiable risk factor(s) should the nurse include in the teaching for this client? Select all that apply.

Patient Data

Exhibits

The client continues to have stable neurologic assessments. The nurse provides interventions to promote client safety while in the hospital. Click to indicate which interventions promote client safety. Each column must have at least one response selected.