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

Shaking that changes the child's handwriting legibility.

Thirst and frequent requests for bathroom breaks.

Refusal to complete written homework assignments.

Bruises on both knees after the weekend.

Sunburn with blisters on the face, arms, and hands.

Answer and Explanation

Correct Answer : A,B,E

Choice A reason: Shaking that affects a child's handwriting could indicate a neurological issue or other medical conditions that require immediate attention. It's essential for teachers to report such observations to the school nurse for proper assessment and intervention.

Choice B reason: Excessive thirst and frequent urination can be signs of diabetes, especially in children. Early detection and management are crucial for the child's health, making it important for teachers to report these symptoms.

Choice C reason: While refusal to complete homework could be related to behavioral or social issues, it is not typically a medical concern that requires the school nurse's intervention unless accompanied by other signs of distress or health problems.

Choice D reason: Bruises could be common in children due to their active nature, especially after a weekend. However, unless there is a pattern or other concerning signs of abuse or a medical condition, bruises alone may not necessitate a referral to the school nurse.

Choice E reason: Sunburn with blisters is a sign of a second-degree burn, which can be serious, especially in children. It is important for teachers to report this to the school nurse so that the child can receive proper care and parents can be advised on treatment and prevention.

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Correct Answer is C

Explanation

Choice A reason: Decreased bowel sounds may indicate gastrointestinal issues but are not directly related to weight gain associated with fluid accumulation in cirrhosis.

Choice B reason: An increased respiratory rate can be a sign of many conditions, including respiratory distress, but it does not correlate specifically with weight gain due to fluid retention in cirrhosis.

Choice C reason: Increased abdominal girth is a common finding in cirrhosis due to ascites, which is the accumulation of fluid in the peritoneal cavity and can lead to significant weight gain.

Choice D reason: Decreased level of consciousness may be a sign of hepatic encephalopathy in cirrhosis but is not a direct correlation to the weight gain reported by the client.

A. Eat a high-protein diet. B. Weigh every morning. C. Perform range of motion exercises. D. Limit fluid intake to 1,500 mL daily.

Correct Answer is B

Explanation

Choice A reason: While nutrition is important, a high-protein diet is not specific to the management of heart failure.

Choice B reason: Weighing every morning allows for monitoring of fluid retention, which is a key aspect of managing heart failure.

Choice C reason: Range of motion exercises are good for overall health but are not specific to heart failure management.

Choice D reason: Limiting fluid intake is important, but it is more critical to monitor weight daily to detect fluid retention early.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with cirrhosis of the liver reports a 5 lb (2.3 kg) weight gain within the last week during a physical assessment. Which assessment finding correlates with the client's report?

Correct Answer is C

Explanation

A client is being discharged home after being treated for heart failure (HF). Which instruction should the nurse include in this client's discharge teaching plan?

Correct Answer is B

Explanation

Patient Data Exhibits The nurse reviews the assessment findings along with the physician orders. Which immediate interventions would the nurse initiate? Select all that apply.

A nurse is caring for a client who has been prescribed parenteral lidocaine. Before administering the medication, the nurse should review the medical record for which condition?

A 22-year-old client is admitted to the hospital in diabetic ketoacidosis (DKA). The client's parent is insisting on knowing the laboratory test results. Which is the best response for the nurse to provide?

The nurse is caring for a client with the sexually transmitted infection (STI) genital herpes. The client reports having had prior sexually transmitted infections. Which response should the nurse provide?

After a partial gastrectomy, in addition to frequent position changes, which postoperative intervention is most beneficial for the nurse to perform to prevent respiratory complications?

A client with osteomyelitis from a compound fracture of the left tibia has an open draining wound and is admitted with a possible methicillin-resistant Staphylococcus aureus (MRSA) infection. What intervention(s) should the nurse include in the plan of care? Select all that apply.

Patient Data Exhibits The nurse reviews new data. Which 5 nursing interventions are indicated for this client?

When caring for a client with full-thickness burns to both lower extremities, which assessment findings warrant immediate intervention by the nurse? Select all that apply.