Question

A nurse is caring for a client in an orthopedic unit.

Answer 1

Correct Answers

Blank 1 Correct Option: compartment syndrome
Blank 2 Correct Option: osteomyelitis

Rationale :

🦵Compartment syndrome is indicated by severe pain, cool limb, absent pulses, delayed capillary refill, numbness, and paralysis, reflecting increased compartment pressure impairing perfusion.

🩸The progression from normal neurovascular status to loss of circulation and function confirms acute ischemia, making this a limb-threatening emergency requiring immediate intervention.

🦠Osteomyelitis is supported by open fracture, internal fixation device, fever, markedly elevated WBC, and drainage, which indicate a developing bone infection.

📊The combination of systemic infection signs and local wound drainage strongly suggests risk for deep tissue and bone infection rather than superficial involvement.

📌Core message

Compartment syndrome = circulation emergency due to increased pressure and ischemia, osteomyelitis = bone infection risk from open fracture, hardware, and infection signs

Answer 2

Correct Answers:

"You can obtain a personal response system that will be activated if you fall."

Rationale :

🏠Personal response systems provide immediate assistance access, allowing older adults to call for help after a fall, promoting independence and safety.

🛑Recommending institutionalization or constant supervision is unnecessary and reduces autonomy, which is not appropriate for a client living independently.

📞Encouraging weekly contact does not address emergency situations, making it insufficient for fall prevention safety.

👵The priority is fall-response preparedness, not relocation or excessive dependency, making a response alert system the safest option.

📌Core message

Personal response systems improve safety by ensuring rapid emergency assistance without reducing independence

Answer 3

Correct Answers:

"The client exhibits impulsive behavior."

Rationale :

🧠Borderline personality disorder is characterized by impulsivity, including risk-taking behaviors and emotional instability.

⚡Clients often demonstrate rapid mood changes, self-harm, and poor impulse control, which are hallmark features.

💔While clinginess can occur, the defining trait is instability in behavior and emotions, not just dependency.

📋Other options relate to different personality disorders such as obsessive-compulsive traits or histrionic features.

📌Core message

Borderline personality disorder involves impulsivity and emotional instability

Answer 4

Correct Answers:

95% full-thickness body burn

Rationale :

🔥A 95% full-thickness burn is life-threatening due to fluid loss, infection risk, and airway compromise, requiring immediate priority.

🩸Triage prioritizes clients with highest survival benefit and critical needs, making severe burns a top emergency.

🦴Amputations and fractures are serious but less immediately fatal compared to extensive burns.

🚑The goal is to identify conditions with rapid deterioration risk, which applies most to massive burns.

📌Core message

Severe burns require highest priority due to rapid fluid loss and infection risk

Answer 5

Correct Answers:

“Older adults report pain less frequently than younger clients."

Rationale :

👵Older adults often underreport pain due to fear, beliefs about aging, or cognitive changes.

⚠️Pain perception is not decreased, and assuming so can lead to undertreatment.

💊Older adults require lower doses, not higher, due to slower metabolism and increased sensitivity.

🚫Opioids can be used but require careful monitoring, not complete avoidance.

📌Core message

Older adults underreport pain, so careful assessment is essential

Answer 6

Correct Answers:

Administer NPH insulin 30 min before breakfast.

Rationale :

💉NPH insulin is an intermediate-acting insulin typically given before meals to manage glucose levels.

❌It is not used for ketoacidosis, which requires rapid-acting insulin.

🚫NPH is never given IV, only subcutaneously.

🧪Cloudy appearance is normal for NPH insulin, so it should not be discarded.

📌Core message

NPH insulin is intermediate-acting and given before meals, and it is normally cloudy

Answer 7

Correct Answers:

Phlebitis

Rationale :

💉Phlebitis presents with redness, warmth, and tenderness at the IV site due to vein inflammation.

🔥These findings differ from infiltration, which shows coolness and swelling.

⚠️Extravasation involves vesicant leakage causing tissue damage, not just inflammation.

✅Circulatory overload presents systemically, not locally at the IV site.

📌Core message

Phlebitis = redness and warmth from vein inflammation

Answer 8

Correct Answers:

Sit at or below the client's eye level during feedings.

Rationale :

👩‍🦲Proper positioning is essential in clients with dysphagia, and sitting at or below eye level promotes safe swallowing mechanics and better control during feeding.

🧠Maintaining upright alignment and visual engagement allows the nurse to closely monitor swallowing ability, facial cues, and signs of aspiration, enhancing feeding safety.

🚫Talking during feeding increases the risk of aspiration because it disrupts the coordination between breathing and swallowing, which is already compromised in dysphagia.

⚠️Clients with dysphagia should perform a chin-tuck maneuver, not lift the chin, because chin elevation opens the airway, increasing the risk of food entering the trachea instead of the esophagus.

💨Coughing should not be discouraged, as it is a protective reflex that helps clear the airway, preventing aspiration pneumonia and further complications.

📌Core message

Dysphagia management requires proper positioning, close observation, and maintaining airway protection, as incorrect techniques like talking during feeding or improper head positioning can significantly increase the risk of aspiration and respiratory complications

Answer 9

Correct Answers

Concerns about coworkers [ Paranoid personality disorder ]
Client statement [ Borderline personality disorder ]
Relationship status [ Borderline personality disorder ]
Skin alterations [ Borderline personality disorder ]
Behavior pattern [ Borderline personality disorder ]

Rationale :

🧠Paranoid personality disorder is characterized by persistent mistrust and suspicion, which is reflected in the client’s belief that coworkers are plotting against them without evidence.

💔Borderline personality disorder involves unstable relationships, as seen in the recent breakup and difficulty maintaining interpersonal connections, which is a hallmark feature of this disorder.

✂️The presence of self-harm behaviors, such as superficial cuts at different healing stages, strongly indicates emotional dysregulation and maladaptive coping, which are classic for borderline personality disorder.

⚡The client’s impulsive behavior, such as purchasing a car without concern for consequences, demonstrates poor judgment and impulsivity, a key diagnostic trait of borderline personality disorder.

📊The overall behavior pattern of emotional instability, impulsivity, and self-harm, combined with interpersonal difficulties, supports borderline personality disorder, while the isolated symptom of mistrust aligns with paranoid personality disorder, explaining the mixed findings.

📌Core message

Paranoid personality disorder involves mistrust and suspicion, while borderline personality disorder is defined by impulsivity, unstable relationships, emotional dysregulation, and self-harm behaviors, requiring careful differentiation based on the client’s overall pattern of symptoms

Answer 10

Correct Answers

Blank 1 Correct Option: inspect the child's oropharynx
Blank 2 Correct Option: obtaining a set of vital signs

Rationale :

🩸The presence of bright red emesis after a tonsillectomy is a critical sign of active hemorrhage, making inspection of the oropharynx the priority to confirm the source and extent of bleeding.

👀Frequent throat clearing and visible bleeding in the posterior pharynx are early indicators of post-tonsillectomy hemorrhage, which can rapidly progress to airway compromise and hypovolemia.

📊Following assessment, obtaining vital signs is essential to evaluate for hemodynamic instability, as evidenced by tachycardia and low hemoglobin, which suggest ongoing blood loss.

🚫Other options such as supine positioning, red popsicles, or coughing are inappropriate because they can worsen bleeding or obscure assessment, delaying recognition of a life-threatening complication.

⚠️Prompt recognition and monitoring are critical to prevent shock and airway obstruction, making assessment followed by physiologic monitoring the correct sequence.

📌Core message

Post-tonsillectomy bleeding requires immediate airway assessment and vital sign monitoring to detect hemorrhage and prevent shock

Potential Assessment Finding	Borderline personality disorder	Paranoid personality disorder
Concerns about coworkers
Client statement
Relationship status
Skin alterations
Behavior pattern

1 :
A nurse is caring for a client in an orthopedic unit.

Correct Answers

2 :
A nurse is teaching a class at a local senior center regarding safety in the home. A client states, "l am afraid of falling because I live alone and have no one to help me." Which of the following statements should the nurse make?

3 :
A nurse is developing an in-service about personality disorders. Which of the following information should the nurse include when discussing borderline personality disorder?

4 :
A nurse in an emergency department is performing triage for multiple clients following a disaster in the community. To which of the following types of injuries should the nurse assign the highest priority?

5 :
A nurse manager is teaching a newly licensed nurse about pain management for an older adult client. Which of the following statements by the nurse indicates an understanding of the teaching?

6 :
A nurse is reviewing the formulary about NPH insulin before administering the medication to a client. Which of the following information should the nurse expect?

7 :
A nurse is assessing the peripheral catheter insertion site of a client who is receiving an infusion. The nurse notices redness and warmth to the touch around the insertion site. The nurse should document the finding as which of the following complications?

8 :
A nurse is preparing to feed a newly admitted client who has dysphagia. Which of the following actions should the nurse plan to take?

9 :
A nurse in an Outpatient mental health center is caring for a client.

Correct Answers

10 :
A nurse is caring for a 9-year-old child on a pediatric unit.

Correct Answers

1 : A nurse is caring for a client in an orthopedic unit.

Correct Answers

2 : A nurse is teaching a class at a local senior center regarding safety in the home. A client states, "l am afraid of falling because I live alone and have no one to help me." Which of the following statements should the nurse make?

3 : A nurse is developing an in-service about personality disorders. Which of the following information should the nurse include when discussing borderline personality disorder?

4 : A nurse in an emergency department is performing triage for multiple clients following a disaster in the community. To which of the following types of injuries should the nurse assign the highest priority?

5 : A nurse manager is teaching a newly licensed nurse about pain management for an older adult client. Which of the following statements by the nurse indicates an understanding of the teaching?

6 : A nurse is reviewing the formulary about NPH insulin before administering the medication to a client. Which of the following information should the nurse expect?

7 : A nurse is assessing the peripheral catheter insertion site of a client who is receiving an infusion. The nurse notices redness and warmth to the touch around the insertion site. The nurse should document the finding as which of the following complications?

8 : A nurse is preparing to feed a newly admitted client who has dysphagia. Which of the following actions should the nurse plan to take?

9 : A nurse in an Outpatient mental health center is caring for a client.

Correct Answers

10 : A nurse is caring for a 9-year-old child on a pediatric unit.

Correct Answers

1 :
A nurse is caring for a client in an orthopedic unit.

2 :
A nurse is teaching a class at a local senior center regarding safety in the home. A client states, "l am afraid of falling because I live alone and have no one to help me." Which of the following statements should the nurse make?

3 :
A nurse is developing an in-service about personality disorders. Which of the following information should the nurse include when discussing borderline personality disorder?

4 :
A nurse in an emergency department is performing triage for multiple clients following a disaster in the community. To which of the following types of injuries should the nurse assign the highest priority?

5 :
A nurse manager is teaching a newly licensed nurse about pain management for an older adult client. Which of the following statements by the nurse indicates an understanding of the teaching?

6 :
A nurse is reviewing the formulary about NPH insulin before administering the medication to a client. Which of the following information should the nurse expect?

7 :
A nurse is assessing the peripheral catheter insertion site of a client who is receiving an infusion. The nurse notices redness and warmth to the touch around the insertion site. The nurse should document the finding as which of the following complications?

8 :
A nurse is preparing to feed a newly admitted client who has dysphagia. Which of the following actions should the nurse plan to take?

9 :
A nurse in an Outpatient mental health center is caring for a client.

10 :
A nurse is caring for a 9-year-old child on a pediatric unit.