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 ["A","C","E"]

Explanation

The observation(s) by the nurse that require immediate intervention to reduce the likelihood of harm to this client are:

A. The client’s oxygen saturation level is 85%. This is a sign of hypoxemia, which can lead to tissue hypoxia, organ damage, and cardiac arrest. The nurse should administer oxygen therapy and monitor the client’s respiratory status closely.

C. The client’s heart rate is 110 beats per minute. This is a sign of tachycardia, which can indicate worsening heart failure, dehydration, infection, or anxiety. The nurse should assess the client’s fluid balance, vital signs, and symptoms and report any changes to the physician. The nurse should also administer medications as prescribed to control the heart rate and reduce the cardiac workload.

E. The client’s blood pressure is 160/90 mmHg. This is a sign of hypertension, which can increase the risk of stroke, myocardial infarction, and renal failure. The nurse should administer antihypertensive medications as prescribed and monitor the client’s blood pressure and urine output. The nurse should also educate the client on lifestyle modifications to lower blood pressure, such as reducing salt intake, exercising, and managing stress .

The other observations do not require immediate intervention, but they should be addressed as part of the comprehensive nursing care plan for the client with heart failure and COPD. These include:

B. The client is eating less than half of meals. This can indicate poor appetite, nausea, dyspnea, or fatigue, which can affect the client’s nutritional status and energy level. The nurse should encourage the client to eat small, frequent, and balanced meals that are low in sodium, fat, and cholesterol. The nurse should also provide oral hygiene and offer supplements or enteral feeding if needed .

D. The client is reading a book. This can indicate that the client is coping well with the condition and engaging in leisure activities that promote relaxation and mental health. The nurse should praise the client for this positive behavior and provide emotional support and counseling as needed. The nurse should also teach the client about the signs and symptoms of exacerbation and when to seek medical help .

A. “You may notice that your reaction time is slower than before.”. B. “You may experience some difficulty with learning new things.”. C. “You may have more neurotransmitters in your brain as you age.”. D. “You may lose some of your sense of smell and taste over time.”. E. “You may have more oxygen delivery to your brain cells as you age.”.

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

Explanation

Choice A rationale:

Slower reaction time is a common age-related change in the neurological system. The processing of sensory information and response time may become slower in older adults due to changes in neural pathways and decreased neurotransmitter activity.

Choice B rationale:

Older adults may experience some difficulty with learning new things due to changes in cognitive function and neural plasticity. This is a common age-related effect on the neurological system.

Choice C rationale:

This statement is incorrect. Older adults typically have fewer neurotransmitters in their brains as they age, which can contribute to cognitive changes and a decline in cognitive function.

Choice D rationale:

Loss of some sense of smell and taste is an age-related change. Older adults may experience a decreased ability to detect and differentiate smells and tastes due to changes in olfactory and gustatory receptors.

Choice E rationale:

This statement is incorrect. Aging does not necessarily lead to an increase in oxygen delivery to brain cells. In fact, there may be a decrease in cerebral blood flow with age in some individuals.

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Naxlex Comprehensive Predictor Exams

A client is admitted with an exacerbation of heart failure secondary to chronic obstructive pulmonary disease (COPD). Which observation(s) by the nurse require immediate intervention to reduce the likelihood of harm to this client? (Select all that apply.).

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

Explanation

A nurse is teaching a group of older adults about the effects of aging on the neurological system. Which of the following statements should the nurse include as correct? (Select all that apply.).

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

Explanation

Patient Data. Exhibits The nurse has called the physician and is anticipating orders. Select the actions that would help with the listed treatment goals. Select all that apply.

A client tells the nurse about beginning an exercise program a month ago to lose weight and improve sleep. The client states that it still takes at least two hours to fall asleep at night. Which action should the nurse implement?

A client is diagnosed with influenza A and is prescribed oseltamivir. Which of the following statements by the client indicates a need for further education?

The practical nurse (PN) is auscultating a client's lung sounds. Which description should the PN use to document this sound? (Please listen to the audio clip provided). Audio: [Wheezing sound]

The nurse is caring for a client with the sexually transmitted infection (STI) syphilis. The client reports having unprotected sex. Which response should the nurse provide?

A client who weighs 176 pounds receives a prescription for norepinephrine 2 mcg/min intravenously (IV). The IV bag is labeled, "Norepinephrine 4 mg in dextrose 5% in water (D;W) 1,000 mL." How many mL/hour should the nurse program the infusion pump? (Enter numerical value only.).