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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Correct Answer is D

Explanation

The correct answer is choiced. Ask the parents to explain what they understand about the child’s diagnosis.

Choice A rationale:

While it is important to support the parents’ decisions, this choice does not address the need for the parents to have accurate information about the condition and its potential complications.

Choice B rationale:

This statement is incorrect.Delaying surgery for hypospadias can lead to complications such as urinary problems, infections, and issues with sexual function later in life.

Choice C rationale:

This is misleading.Hypospadias does not typically resolve on its own, and waiting can result in complications that may require more complex surgical interventions.

Choice D rationale:

This choice is correct because it encourages the parents to share their understanding of the diagnosis, allowing the nurse to provide accurate information and address any misconceptions.This approach ensures that the parents make an informed decision based on a clear understanding of the condition and its implications.

A. Instruct the unlicensed assistive personnel (UAP) to apply a warm blanket and massage the client's back. B. Insert a gloved finger into the rectum and gently massage the rectal sphincter. C. Stop the procedure and observe for a reduction in symptoms before continuing. D. Encourage the client to take slow, deep breaths while continuing the procedure. E. Encourage the client to take slow, deep breaths while continuing the procedure.

Correct Answer is A

Explanation

Choice A rationale:

Instructing the UAP to apply a warm blanket and massage the client's back is the appropriate intervention in response to the client's complaints of feeling dizzy and cold during a fecal impaction removal procedure. These symptoms suggest a vasovagal response, which can be managed by keeping the client warm and providing comfort. This intervention helps increase blood flow and alleviate symptoms.

Choice B rationale:

Inserting a gloved finger into the rectum and massaging the rectal sphincter is not the first-line intervention when a client complains of feeling dizzy and cold during a fecal impaction removal. This invasive procedure should be reserved for cases where other interventions have failed, and it is necessary to complete the impaction removal.

Choice C rationale:

Stopping the procedure and observing for a reduction in symptoms before continuing is a reasonable approach, but it does not address the immediate discomfort and distress the client is experiencing. Providing comfort measures, such as applying a warm blanket and massaging the client's back, should be the initial response.

Choice D rationale:

Encouraging the client to take slow, deep breaths while continuing the procedure may not be effective in addressing the client's symptoms of dizziness and coldness. The client may require immediate comfort measures to stabilize their condition.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The parents of a one-year-old child with the diagnosis of hypospadias informed the practical nurse (PN) that they plan to delay corrective surgery to see if the child will outgrow the problem. Which information should the PN provide to these parents?

Correct Answer is D

Explanation

During a fecal impaction removal, an older client complains of feeling dizzy and cold. Which intervention should the nurse implement?

Correct Answer is A

Explanation

The nurse is developing an educational program for older clients who are being discharged with new antihypertensive medications. The nurse should ensure that the educational materials include which characteristics? (Select all that apply.).

A college student brings his roommate to the clinic because the roommate has been talking to someone who is not present. The student tells the practical nurse (PN) that his roommate is acting strange. Which question should the PN ask the client next?

An unlicensed assistive personnel (UAP) reports that a client's right hand and fingers spasm when taking the blood pressure using the same arm. After confirming the presence of the spasms, which action should the nurse take?

A nurse is updating the plan of care for a client who has a pressure ulcer on the sacrum. Which of the following outcomes are appropriate for this client? (Select all that apply.)

A woman at 12 weeks' gestation comes to the clinic for her first prenatal visit. After completing a health history, the nurse should discuss which topic about pregnancy at this initial visit?

An adult male was diagnosed with stage IV lung cancer three weeks ago. His wife approaches the nurse and asks how she will know that her husband's death is imminent because their two adult children want to be there when he dies. Which is the best response by the nurse?

A nurse is planning recreational activities for a group of patients who are receiving rehabilitation and restorative care. Which of the following factors should the nurse consider when selecting appropriate activities? (Select all that apply.).