1 :

Client hospitalized following a motor vehicle crash. Open fracture to right femur. Reduction of fracture and internal fixation device used to stabilize. Splint applied.

Client is alert to person, place, and time. Lung sounds diminished in the bases bilaterally, no adventitious sounds noted. Client denies shortness of breath. Bowel sounds hypoactive x4, soft abdomen. Splint to right leg clean, dry, and intact. Client rates pain as 6 on a scale of O to IO. Right foot warm to touch, no edema noted. Posterior tibial and dorsalis pedis pulses palpable, and capillary refill to toes less than 2 seconds. Client denies numbness or tingling to right foot.

Day 3, 1200

Client is alert to person, place, and time. Lung sounds clear. Client denies shortness of breath. Bowel sounds active in all 4 quadrants, soft abdomen. Client rates pain as 9 on a scale of O to IO. Right foot cool to touch, 2+ edema noted. Unable to palpate posterior tibial and dorsalis pedis pulses, and capillary refill to toes greater than 2 seconds. Client reports numbness to right foot. Client unable to move toes or right foot. Splint to right leg intact, drainage noted.

Day 2, 0830

Temperature 36.8Β°C (98.2Β°F)

Heart rate 90/min

Respiratory rate 20/min

Blood pressure 132/84 mm Hg

Oxygen saturation 96% on room air

 

Day 3, 0800

Temperature 38.1Β°C (100.6Β°F)

Heart rate 98/min

Respiratory rate 24/min

Blood pressure 128/78 mm Hg

Oxygen saturation 96% on room air

 

1200

Temperature 38.9Β°C (102Β°F)

Heart rate 110/min

Respiratory rate 24/min

Blood pressure 118/68 mm Hg

Oxygen saturation 94% on room air

Day 2

Hemoglobin 10 g/dL (12 to 16 g/dL)

Hematocrit 34% (37% to 47%)

WBC count 14,000/mm3 (5,000 to 10,000/mm3)

 

Day 3

Hemoglobin 9.8 g/dL (12 to 16 g/dL)

Hematocrit 32% (37% to 47%)

WBC count 28,000/mm3 (5,000 to 10,000/mm3)


Drag words from the choices below to fill in each blank in the following sentence. The client is at risk for developingand


Hint : 🧠Think about neurovascular compromise signs and infection risk after open fractures.

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.

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

πŸ“ŒCore message

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

2 :

Hint : 🧠Think about quick emergency help access while living alone.

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.

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

πŸ“žEncouraging weekly contact does not address emergency situations, making it insufficient for fall prevention safety.

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

πŸ“ŒCore message

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

3 :

Hint : 🧠Focus on unstable emotions and risky actions.

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.

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

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

πŸ“ŒCore message

Borderline personality disorder involves impulsivity and emotional instability

4 :

Hint : 🧠Think about injuries that threaten life fastest.

Correct Answers:

  • 95% full-thickness body burn


Rationale :

πŸ”₯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.

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

πŸ“ŒCore message

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

5 :

Hint : πŸ‘΅Think about communication patterns in older adults.

Correct Answers:

  • β€œOlder adults report pain less frequently than younger clients."


Rationale :

πŸ‘΅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.

πŸ’ŠOlder adults require lower doses, not higher, due to slower metabolism and increased sensitivity.

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

πŸ“ŒCore message

Older adults underreport pain, so careful assessment is essential

6 :

Hint : 🍚Think about timing of insulin with meals.

Correct Answers:

  • Administer NPH insulin 30 min before breakfast.


Rationale :

πŸ’‰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.

πŸ§ͺCloudy appearance is normal for NPH insulin, so it should not be discarded.

πŸ“ŒCore message

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

7 :

Hint : 🧠Think inflammation signs at IV site.

Correct Answers:

  • Phlebitis


Rationale :

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

πŸ”₯These findings differ from infiltration, which shows coolness and swelling.

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

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

πŸ“ŒCore message

Phlebitis = redness and warmth from vein inflammation

8 :

Hint : 🧠Think about positioning that improves control and prevents aspiration during swallowing.

Correct Answers:

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


Rationale :

πŸ‘©β€πŸ¦²Proper 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.

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

πŸ“ŒCore 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

9 :

Initial visit

Client accompanied by their partner. Client and partner report that the client has been experiencing difficulties with meeting responsibilities at work and at home. Client also reports not sleeping well and feeling fatigued. Superficial cuts observed on the client's arm at various stages of healing. Client is alert, but blunted affect noted. Client expressed concerns that coworkers are talking behind their back and plotting against them.

 

Follow-up visit 1 month later

Client reports no improvement. Client states they broke up with their partner. Client also states, "l purchased a new car. I'll worry about paying for it when the time comes." Client states they have been seeing a therapist for the past 3 weeks. Would like to discuss possible medications with provider.

Initial visit

Blood pressure 124/80 mm Hg

Heart rate 92/min

Respiratory rate 18/min

Temperature 36.6Β°C (97.9Β°F)

 

Follow-up visit 1 month later

Blood pressure 118/78 mm Hg

Heart rate 88/min

Respiratory rate 18/min

Temperature 36.8Β°C (98.2Β°F)

Initial visit

Client reports no recent illnesses or chronic illnesses. Reports tonsillectomy at 5 years old, no other surgeries. Father has hypertension, mother has hyperlipidemia and borderline personality disorder. Current on all recommended immunizations.


For each potential assessment finding, click to specify if the finding is consistent with paranoid personality disorder or borderline personality disorder. Each finding may support more than 1 personality disorder or none at all. There must be at least 1 selection in every column. There does not need to be a selection in every row.


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

Hint : 🧠Differentiate between chronic mistrust and emotional instability with impulsive actions.

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.

πŸ’”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.

βœ‚οΈ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.

πŸ“ŠThe 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.

πŸ“ŒCore 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

10 :

Day 1, 2200

Child has been admitted to the pediatric unit for observation following tonsillectomy. Parents report child has history of chronic pharyngitis. Child is drowsy, but responsive to verbal stimuli. Respirations even, nonlabored. Heart rate regular. No bleeding noted. Child rates pain as 3 on a scale of O to IO. Head of bed elevated.

 

Day 2, 0800

Child is alert and awake, clears throat often. Small amount of bleeding noted in the posterior pharynx. Breath sounds clear bilaterally. Abdomen soft, nondistended, nontender. Skin dry. Child rates pain as 3 on a scale of 0 to 10.

 

Day 2, 0830

Parent reports child has vomited bright red emesis.

Clear liquids, advance diet as tolerated.

Day 2, 0800

Temperature 36.2Β°C (97.2Β°F)

Heart rate 120/min

Respiratory rate 26/min

Blood pressure 94/74 mm Hg

Day 2, 0800

WBC count 7,500/mm3 (5,000 to 10,000/mm3)

Hemoglobin 8.8 g/dL (1 0 to 15.5 g/dL)

Hematocrit 29% (32% to 44%)


Complete the following sentence by using the lists of options. The nurse should plan tofollowed by


Hint : 🧠Think about priority assessment first, then monitor for instability in a bleeding complication.

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.

πŸ‘€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.

πŸ“ŠFollowing 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.

πŸ“ŒCore message

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

Total Questions: 10

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