1 :

Today

0800:

Client presents to the clinic with reports of restlessness, abdominal pain, disorientation, and fei.br for the past 1 2 hr. States, "l don’t know what is wrong with me." Client denies recent illness. Denies fatigue and chills. Reports falling yesterday but didn't hit their head. Reports taking ibuprofen for muscle soreness. Client reports continued sleep disturbances, feelings of hopelessness, and a disinterest in activities.

1 week ago:

Client reports the manifestations of hopelessness and disinterest are lessened, but present. Sleep disturbance continues. Provider increased paroxetine to 30 mg daily. Return to clinic in 1 week.

2 weeks ago:

Client With a history of generalized anxiety disorder and major depressive disorder. Client presents with increased hopelessness, disinterest, and a change in sleep and appetite over several months. Client is currently taking fluoxetine 20 mg daily for the past year. Fluoxetine discontinued and paroxetine 10 mg daily started. Return to clinic in 1 week.


Complete the following sentence by using the lists of options. The client is at a risk for developingdue to.


Hint : πŸ”Watch for rapid onset of confusion, hyperthermia, and agitation after changes in serotonergic medication.

Correct Answers

  • Blank 1 Correct Option: serotonin syndrome
  • Blank 2 Correct Option: adverse effects of paroxetine

Rationale :

πŸ’ŠSerotonin syndrome occurs when there is excessive serotonergic activity, often due to medication interactions or dose increases.

πŸ§ͺThe client’s recent dose increase of paroxetine, a selective serotonin reuptake inhibitor (SSRI), places them at risk for this potentially life-threatening reaction.

⚠️Manifestations such as restlessness, abdominal pain, disorientation, and fever are classic warning signs of serotonin syndrome.

🩺Prompt recognition and discontinuation of the offending drug are critical to prevent neuromuscular, autonomic, and cognitive complications.

πŸ“ŒCore Message

Recent SSRI dose increases can trigger serotonin syndrome, requiring urgent recognition and intervention.

2 :

Hint : ⚑Look for the safest option that prevents shock by redirecting current away from the body.

Correct Answers:

  • β€˜β€™Use three-pronged grounded plugs.’’


Rationale :

πŸ”ŒThree-pronged grounded plugs provide a direct path to ground, reducing the risk of electrical shock and fire.

πŸ›‘οΈGrounding prevents the buildup of static electricity and safely redirects stray current away from the user.

🚫In contrast, practices like covering cords with rugs or pulling plugs by the cord increase the risk of overheating, damage, and fire hazards.

🏠Teaching proper electrical safety can significantly reduce the incidence of electrical fires in the community.

πŸ“ŒCore Message

Grounded plugs are essential for electrical fire prevention and personal safety.

3 :

Hint : πŸ”“Once safety is ensured and behavior is under control, the most restrictive measures should be stopped immediately.

Correct Answers:

  • Remove the restraints from the client.


Rationale :

πŸ›‘Restraints should be discontinued as soon as the client is calm and cooperative to uphold patient rights and safety.

βš–οΈProlonged restraint use increases risks of injury, psychological distress, and impaired circulation.

🩺Assessment should always guide restraint use, ensuring they remain a last resort and are removed promptly when no longer needed.

πŸ’¬Transitioning to less restrictive interventions helps promote trust, autonomy, and therapeutic rapport.

πŸ“ŒCore Message

Restraints must be removed promptly when the client regains control and safety is no longer at risk.

4 :

Hint : 🧠Think about the safest primary nutrition source for infants under 12 months that prevents iron deficiency.

Correct Answers:

  • Advise the parent to avoid giving cow’s milk to the infant prior to 1 year of age.


Rationale :

πŸ₯›Cow’s milk before 12 months lacks essential nutrients such as iron and can cause gastrointestinal irritation.

⚠️Early introduction may lead to iron-deficiency anemia due to microscopic GI bleeding and poor iron absorption.

🧴Infants should receive breast milk or iron-fortified formula as their primary nutrition during the first year.

πŸ“ˆDelaying cow’s milk introduction supports optimal growth, development, and digestive system maturity.

πŸ“ŒCore Message

Cow’s milk should be avoided before 1 year to prevent iron deficiency and GI irritation.

5 :

Hint : 🚽Think about physical changes in the urinary tract that can block urine flow without involving excess fluid intake.

Correct Answers:

  • "can be caused by inflammation of the urethra."


Rationale :

🩺Urinary retention occurs when urine cannot flow normally from the bladder, often due to obstruction or inflammation.

🦠Inflammation of the urethra can narrow the passage, making urination difficult and incomplete.

🚫Conditions like urethritis, prostatitis, or post-surgical swelling can trigger this mechanism.

πŸ’§Recognizing inflammatory causes allows targeted treatment to restore bladder emptying and prevent complications.

πŸ“ŒCore Message

Inflammation of the urethra can cause urinary retention by obstructing urine flow.

6 :

Hint : πŸ”Watch for small behavioral or physical changes that may appear before hallucinations or delusions.

Correct Answers:

  • Decrease in appetite.


Rationale :

🧠Early manifestations of psychosis often include subtle changes in mood, behavior, and physiological patterns.

🍽️Loss of appetite can signal withdrawal, altered thought processes, or diminished interest in self-care.

🩺Other physical changes, like disturbed sleep and social withdrawal, can accompany these early warning signs.

⚠️Identifying such subtle symptoms early allows timely intervention to prevent progression to acute psychosis.

πŸ“ŒCore Message

Loss of appetite can be an early indicator of psychosis in schizophrenia.

7 :

4 weeks ago:

21 -year-old client reports increased stress and worry for the last 3 months. Client is worried about academic performance due to inability to focus on studies. School performance is suffering. Denies illicit drug use and drinks in moderation socially on the weekends. Discussed lifestyle modifications to reduce stress. Instructed client to return in 1 month to reevaluate symptoms.

Today:

Client reports a slight improvement in stress but is now having loss of appetite and difficulty sleeping. Instructed client to begin trazodone per provider's prescription.

Graphic Record

4 weeks ago:

Weight 54.4 kg (120 lb)

Height 162.6 cm (64 in)

BMI 20.6

Today:

Weight 51.7 kg (114 lb)

Height 162.6 cm (64 in)

BMI 19.6 .


For each potential nursing intervention. click to specify if the intervention is indicated or not indicated.


Nursing Intervention Indicated Not indicated
Encourage naps during the day when client is tired
Instruct client to avoid foods that have been fermented or aged
Advise client to rise slowly from sitting position
Encourage client to sleep until later in the morning
Advise client to notify provider if pregnant
Encourage high-calorie finger foods
Encourage a regular sleep-wake schedule

Hint : 🩺Focus on preventing side effects, maintaining nutrition, and promoting a healthy sleep cycle for someone starting antidepressant therapy.

Correct Answers

  • Encourage naps during the day when client is tired [ Not indicated ]
  • Instruct client to avoid foods that have been fermented or aged [ Indicated ]
  • Advise client to rise slowly from sitting position [ Indicated ]
  • Encourage client to sleep until later in the morning [ Not indicated ]
  • Advise client to notify provider if pregnant [ Indicated ]
  • Encourage high-calorie finger foods [ Indicated ]
  • Encourage a regular sleep-wake schedule [ Indicated ]

Rationale :

πŸ’ŠTrazodone is an antidepressant often used for clients with insomnia and depressive symptoms, but it can cause orthostatic hypotension; hence, rising slowly is advised.

πŸ₯—It interacts with tyramine-rich foods (fermented/aged) when combined with certain antidepressants, though this is more critical with MAOIs, so dietary guidance is still prudent.

πŸ›οΈDaytime napping and sleeping late can worsen circadian rhythm disruption and lead to poor nighttime sleep quality.

🍽️High-calorie finger foods help counter weight loss from reduced appetite, and pregnancy notification is essential due to potential medication risks to the fetus.

πŸ“ŒCore Message

Trazodone management requires orthostatic hypotension precautions, nutrition support, and consistent sleep hygiene.

8 :

1300:

Child is accompanied by their parent, Parent reports that their child is experiencing stomach pain and occasional vomiting. Parent states the child eats well, but sometimes has severe pain that causes them to "draw their knees to their chest" and scream, but then returns to being themselves. Parent noted blood and mucus in the child's bowel movement today.

1310:

Child is alert and responsive to verbal stimuli. Pain rated as 5 on the Facial expression, Leg movement, Activity, Cry. Consolability (FLACC) scale. Lung sounds clear anterior and posterior. Respirations even, nonlabored. Heart rate regular. Abdomen distended with hypoactive bowel sounds x 4 quadrants and tenderness with light palpation noted in right upper quadrant. Small, oblong. palpable mass noted in upper right quadrant.

1315:

Child vomited approximately 50 mL light-colored emesis.


Which condition should the nurse suspect?


Answer Options

Hint : 🧭Think of a pediatric emergency where one part of the intestine slides into another causing episodic pain and bloody mucus stools.

Correct Answers:

  • Intussusception


Rationale :

🩺Intussusception occurs when a segment of bowel telescopes into an adjacent segment, producing bowel obstruction and impaired perfusion that can rapidly progress to ischemia.

πŸ”ŽThe toddler’s intermittent, colicky abdominal pain with drawing the knees to the chest, episodes of vomiting, and bloody mucus stools (often termed β€œcurrant jelly”) are classic findings for this diagnosis.

⚠️The presence of a palpable sausage‑shaped mass in the right abdomen with distension and hypoactive bowel sounds strongly supports intussusception over other pediatric GI conditions.

πŸš‘Management requires urgent reductionβ€”typically via air or contrast enemaβ€”to relieve the obstruction and prevent necrosis or perforation.

πŸ“ŒCore Message

Episodic abdominal pain, bloody mucus stool, and a palpable sausage‑shaped mass point to intussusception, which needs urgent reduction.

9 :

Hint : πŸ›οΈConsider who has both limited mobility and constant skin moisture exposure.

Correct Answers:

  • A client who has dementia and is incontinent of urine.


Rationale :

πŸ›οΈDementia limits mobility and awareness, increasing time spent in one position and delaying pressure relief.

πŸ’§Urinary incontinence contributes to skin maceration, making the skin more vulnerable to breakdown.

⚠️These combined factors create a high-risk profile for pressure injury development.

🩺Prevention includes frequent repositioning, incontinence care, and skin protection strategies.

πŸ“ŒCore Message

Dementia with incontinence greatly increases the risk of pressure injury.

10 :

1 week ago:

Guardians report 2-day history of fever, congestion, and cough. Toddler fussy. moderate amount of clear, thick nasal drainage noted. Frequent loose, non-productive cough. Lungs sound clear. Respirations easy and unlabored.

Today:

Guardians report toddler continues with a fever and is now vomiting and difficult to rouse. Guardians report administering aspirin and acetaminophen alternately during the past week. Toddler lethargic and frequently vomiting small amounts of clear fluid. Respirations easy and unlabored. nonproductive cough noted. Mucus membranes slightly dry. Guardians report no void today.

1 week ago:

Heart rate 114fmin

Respiratory rate 30/min

Temperature 38.8Β°C (101.8Β°F)

Today:

Heart rate 120fmin

Respiratory rate 22/min

Temperature 39Β°C (102.2Β°F)

1 week ago:

Treat with antipyretics. 

Encourage fluid intake. 

Return to office if manifestations worsen.

Start prescription for oseltamivir for 5 days.

1 week ago:

Influenza A positive (negative)

Influenza B negative (negative)


Complete the following sentence by using the lists of options. The nurse recognizes the toddler has likely developeddue to.


Hint : πŸ§ͺThink about a dangerous brain and liver complication that happens when aspirin is given after viral illness.

Correct Answers

  • Blank 1 Correct Option: Reyes syndrome
  • Blank 2 Correct Option: aspirin administration

Rationale :

🧠Reye’s syndrome is a rare but serious condition causing acute encephalopathy and liver dysfunction, often after viral illness.

⚠️It is strongly linked to aspirin use in children and adolescents with viral infections such as influenza.

🀒Symptoms include vomiting, lethargy, confusion, and in severe cases, seizures or coma.

🚫Prevention involves avoiding aspirin in children unless specifically indicated for certain conditions.

πŸ“ŒCore Message

Aspirin after viral infection can cause Reye’s syndrome in children.

Total Questions: 10

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