Question 1
Anurse in an emergency department is caring for a child who reports being sexually abused by a family member. Which of the following actions
should the nurse take?
I I L T
© Use leading statementsto obtain information from the child.
© nsure that multiple nurses are present for the physical examination.
© Explain to the child what will happen when the abuse is reported.
3
O Reassure the child that no one will be told about the abuse.
Question 2
Anurse is caring for a client in an emergency department. Complete the diagram by dragging from the choices below to specify
what condition the client is most likely experiencing, 2 actions the nurse
Ehibit! Exhibiz Exhibits should take to address that condition, and 2 parameters the nurse
should monitor to assess the client's progress
Nurses’ Notes. B R I
Day 1 Parameter to Menitor 1
0400:
Client brought in by emergency medical services (EMS) after et i
being found roaming around the college and yelling. Client ran
from EMS shouting, "No, you are not going to kill me,” and only
agreed to seek assistance when another student agreed to Actions to Take Potential Condition
accompany the client to the emergency department.
Acquaintance reports hearing rumors that the client had odd
behaviors like mumbling and talking when no one else was
there and always seemed suspicious of everyone.
Client appears disheveled and states, "l feel ho
Informed client that they were in the emergency department.
Assisted client in changing into a hospital gown. Client was
cooperative and appears less anxious. e
0415:
‘ Temperature
Client tearfully agreed to be admitted to the mental health unit. ‘
Day 2
, A nurse is caring for a client in an emergency department.
Exhibit 1 Exhibit 2 Exhibit 3
Laboratory Results
0445:
Blood alcohol O mg/dL (O to 50 mg/dL)
Sodium 140 MEQ/L (136 to 145 mEqg/L)
Potassium 3.5 mEQ/L (3.5 to 5.0 mEqQ/L)
Chloride 100 mEQ/L (98 to 106 mEQ/L)
BUN 18 mg/dl (10 to 20 mg/dl)
WBC count 5,500/mm? (5,000 to 10,000/mm?)
Glucose 94 mg/dL (74 to 106 mg/dL)
C-reactive protein 0.8 mg/L (less than 1.0mg/dL)
Question 4
A nurse is caring for a client in an emergency department.
Exhibit 1 Exhibit 2
Vital Signs
0415:
Temperature 37° C (98.6° F)
BP 128/66 mm Hg
Heart rate 88/min
Respiratory rate 20/min
Oxygen saturation 98% room air
, Anurse in an emergency department i caring for a clent. Click to highlight the findings that require follow-up. To deselect a
finding, click on the finding again
[ S P cessscsesssessestr e
History
and Physical
0400
57-year-old male client presents to the emergency department
with severe abdominal and epigastric pain that began about 12
hr ago. Client rates pain as a 7 on a 0to 10 pain scale. Client
reports pain worsens after eating and radiates into his back
States is nauseous and has had several episodes of vomiting.
Reports some shortness of air and increased pain when lying.
flat.
Client s alert and orlented x4 but appears ll. Sclera and palate
noted to be yellow. Abdomen distended, rigid, and tender to
palpation. Skin turgor poor.
Client reports consuming 3 to 4 alcoholic drinks per day, denies
use of other substances, No known allergies.
0730;
Will admit to medical-surgical unit for treatment of pancreatits.
Treatment plan discussed with client.
Question 5
Question 6
Anurse in an emergency department i caring for a client. For each finding, click to specify if the finding is consistent with
pancreatitis or peritonitis.
Exhibit 1 Exhibit 2 Exhibit 3 Exhibit 4 Each finding may support more than one disease process.
History
and Physical
5455 Finding Pancreatitis Peritonitis
57-year-old male client presents to the emergency department Bloady stools O O
With severe abdominal and epigastric pain that began about 12 Hyperbilirubinemia
hr ago. Client rates pain a 7 on a 0 to 10 pain scale. Client e | ]
reports pain worsens after eating and radiates into his back Abdominal pain O [m]
States is nauseous and has had several episades of vomiting.
Reports some shortness of air and increased pain when lying Elevated WBC count O O
flat. X
Client is alert and oriented x4 but appears il. Sclera and palate Note: Each column must have at least 1 response option selected.
noted to be yellow. Abdomen distended, rigid, and tender to
palpation. Skin turgor poor.
Client reports consuming 3 to 4 alcoholic drinks per day, denies
use of other substances. No known allergies.
0730:
Will admit to medical-surgical unit for treatment of pancreatitis.
Treatment plan discussed with client.
Question 7
Anurse in an emergency department is caring for a child who reports being sexually abused by a family member. Which of the following actions
should the nurse take?
I I L T
© Use leading statementsto obtain information from the child.
© nsure that multiple nurses are present for the physical examination.
© Explain to the child what will happen when the abuse is reported.
3
O Reassure the child that no one will be told about the abuse.
Question 2
Anurse is caring for a client in an emergency department. Complete the diagram by dragging from the choices below to specify
what condition the client is most likely experiencing, 2 actions the nurse
Ehibit! Exhibiz Exhibits should take to address that condition, and 2 parameters the nurse
should monitor to assess the client's progress
Nurses’ Notes. B R I
Day 1 Parameter to Menitor 1
0400:
Client brought in by emergency medical services (EMS) after et i
being found roaming around the college and yelling. Client ran
from EMS shouting, "No, you are not going to kill me,” and only
agreed to seek assistance when another student agreed to Actions to Take Potential Condition
accompany the client to the emergency department.
Acquaintance reports hearing rumors that the client had odd
behaviors like mumbling and talking when no one else was
there and always seemed suspicious of everyone.
Client appears disheveled and states, "l feel ho
Informed client that they were in the emergency department.
Assisted client in changing into a hospital gown. Client was
cooperative and appears less anxious. e
0415:
‘ Temperature
Client tearfully agreed to be admitted to the mental health unit. ‘
Day 2
, A nurse is caring for a client in an emergency department.
Exhibit 1 Exhibit 2 Exhibit 3
Laboratory Results
0445:
Blood alcohol O mg/dL (O to 50 mg/dL)
Sodium 140 MEQ/L (136 to 145 mEqg/L)
Potassium 3.5 mEQ/L (3.5 to 5.0 mEqQ/L)
Chloride 100 mEQ/L (98 to 106 mEQ/L)
BUN 18 mg/dl (10 to 20 mg/dl)
WBC count 5,500/mm? (5,000 to 10,000/mm?)
Glucose 94 mg/dL (74 to 106 mg/dL)
C-reactive protein 0.8 mg/L (less than 1.0mg/dL)
Question 4
A nurse is caring for a client in an emergency department.
Exhibit 1 Exhibit 2
Vital Signs
0415:
Temperature 37° C (98.6° F)
BP 128/66 mm Hg
Heart rate 88/min
Respiratory rate 20/min
Oxygen saturation 98% room air
, Anurse in an emergency department i caring for a clent. Click to highlight the findings that require follow-up. To deselect a
finding, click on the finding again
[ S P cessscsesssessestr e
History
and Physical
0400
57-year-old male client presents to the emergency department
with severe abdominal and epigastric pain that began about 12
hr ago. Client rates pain as a 7 on a 0to 10 pain scale. Client
reports pain worsens after eating and radiates into his back
States is nauseous and has had several episodes of vomiting.
Reports some shortness of air and increased pain when lying.
flat.
Client s alert and orlented x4 but appears ll. Sclera and palate
noted to be yellow. Abdomen distended, rigid, and tender to
palpation. Skin turgor poor.
Client reports consuming 3 to 4 alcoholic drinks per day, denies
use of other substances, No known allergies.
0730;
Will admit to medical-surgical unit for treatment of pancreatits.
Treatment plan discussed with client.
Question 5
Question 6
Anurse in an emergency department i caring for a client. For each finding, click to specify if the finding is consistent with
pancreatitis or peritonitis.
Exhibit 1 Exhibit 2 Exhibit 3 Exhibit 4 Each finding may support more than one disease process.
History
and Physical
5455 Finding Pancreatitis Peritonitis
57-year-old male client presents to the emergency department Bloady stools O O
With severe abdominal and epigastric pain that began about 12 Hyperbilirubinemia
hr ago. Client rates pain a 7 on a 0 to 10 pain scale. Client e | ]
reports pain worsens after eating and radiates into his back Abdominal pain O [m]
States is nauseous and has had several episades of vomiting.
Reports some shortness of air and increased pain when lying Elevated WBC count O O
flat. X
Client is alert and oriented x4 but appears il. Sclera and palate Note: Each column must have at least 1 response option selected.
noted to be yellow. Abdomen distended, rigid, and tender to
palpation. Skin turgor poor.
Client reports consuming 3 to 4 alcoholic drinks per day, denies
use of other substances. No known allergies.
0730:
Will admit to medical-surgical unit for treatment of pancreatitis.
Treatment plan discussed with client.
Question 7
