Extract:

Question 1 of 5

A nurse is reinforcing teaching with a parent of a preschooler about immunizations. Which of the following statements by the parent indicates an understanding of the teaching?

A. I understand that immunizations will be withheld if my child has lactose intolerance.B. I can make several office visits, so my child does not get so many immunizations at once.C. It is recommended that my child receive his first flu immunization at the age of 6.D. My child will need to start the human papillomavirus series when he enters kindergarten.

Correct Answer: B

Rationale: Scheduling multiple visits to spread out immunizations shows understanding of flexibility in the schedule. Lactose intolerance doesn't affect vaccines, flu starts at 6 months, and HPV is for older kids.

Extract:

Nurses Notes
Day 1, 12:00:
Transferred to medical-surgical unit from emergency department (ED) for continued care following a closed reduction and immobilization of a fracture of the right arm. Accompanied by adult child.
Client in visibly soiled night clothes with multiple stains, including what appears to be dried blood. Hair, teeth, and fingernails unclean. Strong body odor noted. Bruising of various stages noted around upper arms, back, shoulders, and neck area.
Client is soft-spoken, speaks almost in a whisper, does not make eye contact with nurse.
Client looks at their child before answering the nurse's questions and, when asked how the injury occurred, mumbles, "I don't know. Ask them." Client's child states, "He gets confused sometimes. I can answer your questions."

Question 2 of 5

Nurses Notes Day 1, 12:00: Transferred to medical-surgical unit from emergency department (ED) for continued care following a closed reduction and immobilization of a fracture of the right arm. Accompanied by adult child. Client in visibly soiled night clothes with multiple stains, including what appears to be dried blood. Hair, teeth, and fingernails unclean. Strong body odor noted. Bruising of various stages noted around upper arms, back, shoulders, and neck area. Client is soft-spoken, speaks almost in a whisper, does not make eye contact with nurse. Client looks at their child before answering the nurse's questions and, when asked how the injury occurred, mumbles, 'I don't know. Ask them.' Client's child states, 'He gets confused sometimes. I can answer your questions.' The nurse is identifying tertiary prevention strategies to implement for this client. Select the three actions the nurse should take.

A. Insist that the client explain the reason for their bruises.B. Inform the client that their child is being abusive toward them.C. Report suspected maltreatment to the appropriate agency.D. Confront the client's child about the client's injuries.E. Ask the client how the fracture occurred.F. Conduct the interview with the client privately.

Correct Answer: C,E,F

Rationale: Reporting suspected abuse, asking about the fracture, and interviewing privately are tertiary prevention steps to address and mitigate harm. Insisting, informing, or confronting may escalate without evidence.

Extract:

Question 3 of 5

A nurse is assisting with the admission of an adolescent client who is suspected to have bacterial meningitis. Which of the following findings should the nurse expect?

A. 2+ pedal edemaB. JaundiceC. Nuchal rigidityD. Hematuria

Correct Answer: C

Rationale: Nuchal rigidity (neck stiffness) is a classic sign of bacterial meningitis due to meningeal inflammation. Edema, jaundice, and hematuria suggest other conditions.

Question 4 of 5

A nurse is reinforcing teaching with a client who has a new prescription for esomeprazole. Which of the following statements should the nurse include?

A. You should take this medication at bedtime.B. You might notice an increase in your appetite.C. This medication might cause drowsiness.D. You should report any new abdominal pain to your provider.

Correct Answer: D

Rationale: Abdominal pain could signal a serious issue (e.g., ulcer complication) with esomeprazole, requiring reporting. It's taken before meals, doesn't affect appetite, and drowsiness isn't typical.

Question 5 of 5

A nurse is caring for a client who has a new prescription for amitriptyline. Which of the following findings should the nurse identify as an adverse effect of the medication?

A. Increased energyB. Dry mouthC. Improved moodD. Weight loss

Correct Answer: B

Rationale: Amitriptyline, a tricyclic antidepressant, commonly causes dry mouth due to anticholinergic effects. Energy may decrease, mood improves over time, and weight gain is more likely.