The mother of a school-aged boy tells the practical nurse (PN) that he fell out of a tree and hurt his arm and shoulder. The mother says the boy is in pain and needs medical help.
The nurse should assess the injury and decide the appropriate action to take.
Help the nurse reason out the best assessment.

The injury may require medical attention, as the mother mentioned that the boy is in pain

The abrasions on the boy's leg and hand have healed

The mother describes what she did after her child got injured

The boy lacks coordination when answering the nurse's questions

Answer and Explanation

The Correct Answer is A

A - The injury may require medical attention, as the mother mentioned that the boy is in pain. Correct

This is the correct answer, as it reﬂects the nurse's assessment of the injury and the appropriate action to take. The nurse should consider the mother's report of pain as a valid indicator of the severity of the injury, and should not dismiss or minimize it.

The nurse should also observe the boy's arm and shoulder for any signs of fracture, dislocation, swelling, bruising, or deformity, and ask him to rate his pain on a scale of 0 to 10. The nurse should then decide whether to refer the boy to a physician or an emergency department for further evaluation and treatment.

B - The abrasions on the boy's leg and hand have healed.

This is not the correct answer, as it does not reﬂect the nurse's assessment of the injury or the appropriate action to take. The abrasions on the boy's leg and hand are not relevant to his current complaint of arm and shoulder pain, and do not indicate whether he needs medical attention or not. The nurse should focus on the boy's primary concern and not distract him with unrelated questions or comments.

C - The mother describes what she did after her child got injured.

This is not the correct answer, as it does not reﬂect the nurse's assessment of the injury or the appropriate action to take. The mother's description of what she did after her child got injured may provide some useful information, such as how long ago the injury occurred, what first aid measures were applied, and whether there was any improvement or worsening of symptoms. However, it does not directly answer the question of whether the injury requires medical attention or not. The nurse should listen to the mother's account, but also perform a physical examination and ask relevant questions to assess the injury.

D - The boy lacks coordination when answering the nurse's questions.

This is not the correct answer, as it does not reﬂect the nurse's assessment of the injury or the appropriate action to take. The boy's lack of coordination when answering the nurse's questions may indicate a possible head injury, concussion, or shock, which are serious complications that require immediate medical attention. However, it does not directly relate to his arm and shoulder pain, which is his main complaint.

The nurse should assess the boy's mental status and neurological function, but also evaluate his arm and shoulder for any signs of damage or inﬂammation.

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A rationale:

Observing for signs of depression is the most important intervention for the nurse to include in the client's plan of care. This patient has a history of struggling with weight management, diabetes mellitus, and hypertension, and is now approved for gastroplasty. Weight management surgery can have significant psychological implications, and patients may experience depression or other emotional issues. Identifying signs of depression and providing appropriate support and resources is crucial for the client's overall well-being and successful outcomes.

Choice B rationale:

Monitoring for urinary incontinence is not the top priority in this case. While it's important to assess and address urinary incontinence when necessary, it is not the most critical concern for a client undergoing gastroplasty. Depression and post-surgical complications related to weight management surgery take precedence.

Choice C rationale:

Providing a wide variety of meal choices is not the most important intervention at this stage. After gastroplasty, dietary choices are typically restricted, and the focus is on a controlled and healthy diet. The priority is addressing the psychological and emotional aspects of the client's care, as well as monitoring for surgical complications.

Choice D rationale:

Applying sequential compression stockings is not the most crucial intervention in this situation. While prophylaxis against deep vein thrombosis (DVT) is important, it is not the top priority compared to addressing potential depression and emotional well-being in a client who has struggled with weight management for years.

A. Provide a safe and calm environment for the client during a panic attack. B. Use therapeutic communication skills to establish rapport and trust with the client. C. Educate the client about panic disorder and its treatment options. D. Encourage the client to participate in cognitive-behavioral therapy (CBT). E. Refer the client to self-help groups for peer support and education.

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

Explanation

Choice A rationale:

Provide a safe and calm environment for the client during a panic attack. Creating a safe and calm environment is crucial during a panic attack. It can help the client feel more secure and reduce the intensity and duration of the panic attack.

Choice B rationale:

Use therapeutic communication skills to establish rapport and trust with the client. Therapeutic communication is essential for clients with panic disorder. It helps establish a trusting relationship between the nurse and the client, which is crucial for effective treatment and support.

Choice C rationale:

Educate the client about panic disorder and its treatment options. Educating the client about their condition and available treatment options empowers them to make informed decisions about their care. It also reduces anxiety and fear associated with the disorder.

Choice D rationale:

Encourage the client to participate in cognitive-behavioral therapy (CBT). Cognitive-behavioral therapy is a well-established and effective treatment for panic disorder. Encouraging the client to participate in CBT can help them develop coping strategies and manage their symptoms.

Choice E rationale:

Refer the client to self-help groups for peer support and education. Self-help groups can provide valuable peer support and education to individuals with panic disorder. Being part of such a group can reduce feelings of isolation and provide practical advice for managing the condition.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A nurse is providing interventions for a client with panic disorder. Which interventions should the nurse include in the plan of care? (Select all that apply).

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

Explanation

Which problem reported by a client taking lovastatin requires the most immediate follow-up by the nurse?

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A nurse is assessing a client with panic disorder. Which statement by the nurse would be appropriate during the assessment?

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