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 B

Explanation

The correct answer is Choice B: Advise the client that lifestyle changes often take several weeks to be effective.

Choice B rationale: Exercise is known to improve sleep quality and reduce the time it takes to fall asleep; however, these benefits may not be immediate. Lifestyle modifications, such as incorporating regular physical activity, typically require several weeks before noticeable improvements in sleep patterns and overall health are observed. By informing the client about this expected timeframe, the nurse promotes realistic expectations and encourages adherence to the exercise program.

Choice A rationale: Encouraging daily exercise to eliminate bedtime wakefulness may be counterproductive, as overexertion can lead to increased arousal and impaired sleep quality. Additionally, daily exercise might be too rigorous or impractical for some individuals, potentially leading to burnout or injury. It is essential to tailor exercise recommendations to the client's fitness level, preferences, and goals.

Choice C rationale: While obtaining information about the client's exercise schedule is helpful in assessing their adherence and progress, it does not directly address the issue of sleep onset difficulties. The nurse should focus on providing education and guidance on the expected timeline for observing sleep improvements with exercise.

Choice D rationale: Weight loss is a potential outcome of increased physical activity but is not directly correlated with improvements in sleep onset latency. Focusing solely on weight loss may overlook other essential aspects of sleep hygiene and healthy lifestyle changes. The nurse should emphasize the broader benefits of exercise and provide a comprehensive approach to addressing the client's concerns.

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

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?

Correct Answer is B

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

A client who is reaching saturation with medication reports the onset of muscle soreness and fatigue, and the practical nurse (PN) notes that the client's skin is warm to the touch. Which action by the PN is a priority?

The healthcare provider prescribes the antibiotic cefdinir 300 mg by mouth every 12 hours for a client with a postoperative wound infection. Which foods should the nurse encourage this client to eat?

After receiving a change of shift report for clients on a medical surgical unit, which task should the nurse assign to an unlicensed assistive personnel (UAP)?

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).

An unresponsive male victim of a diving accident is brought to the emergency department where it is determined that immediate surgery is required to save his life. The client is accompanied by a close friend, but no family members are available. Which action should the nurse take first?

The nurse is preparing a community outreach program on primary disease prevention. Which topic should the nurse plan to include in this event?