PN Comprehensive Online Practice 2023 B – Questions
& Verified Answers
A nurse is collecting data on a newborn who is 3 days old.
Exhibit 1
History and Physical
Newborn was delivered at 37 weeks gestation via cesarean section for fetal
distress.Apgar scores 8 at 1 min and 9 at 5 min.Birthweight 2,892 g (6 lb 6
oz)The client who gave birth plans to breastfeed.
Exhibit 2
Flow Sheet
Day 2 of Life
0900:
Temperature 36.7° C (98° F)Heart rate 140/minRespiratory rate
48/minWeight 2,718 g (6 lb), 6% weight lossDay 3 of Life
0800:
Temperature 36.4° C (97.5° F)Heart rate 140/minRespiratory rate
48/minWeight 2,545 g (5 lb 9 oz), 12% weight loss
Exhibit 3
Nurses' Notes
Day 3 of Life
0800:
Skin color consistent with newborn's genetic background. Respirations easy
and unlabored. Abdomen soft with active bowel sounds. Mild tremors noted
when awake. Anterior fontanel level and soft. Large ecchymotic caput
succedaneum noted on posterior scalp. Small amount of bloody mucus
discharge noted from vag Correct Ans - Click to highlight the findings
that require follow-up. To deselect a finding, click on the finding again.
Temperature 36.4° C (97.5° F)
Weight 2,545 g (5 lb 9 oz) 12% weight loss
Mild tremors noted when awake.
Breastfeeding every 3 to 5 hr for 5 to 10 min.
Birth parent reports nipple discomfort throughout the feeding.
,When recognizing cues, the nurse should identify that a temperature of 36.4°
C (97.5° F) is below the expected reference range. Hypothermia can lead to
the occurrence of hypoglycemia and respiratory distress. The newborn
breastfeeding for short intervals, nipple discomfort, and a weight loss of
greater than 10% of birth weight can indicate inadequate transfer of
breastmilk, which can result in hypoglycemia. The presence of mild tremors
can be a manifestation of hypoglycemia.
A nurse is assisting with the care of a client who was admitted to the
emergency department (ED).
Exhibit 1
Admission Assessment
Day 1
1930:
Client admitted to the ED by police after report of violent behavior in public.
Client smashed a glass window with their hands. Client is stating, "I am Jesus."
Client is attempting to hit staff. Client placed in restraints. Neuro: Client is
alert and oriented x 0. Client is swinging their arms and shouting. Client is
unable to answer questions and their speech is rapid and unorganized. Heart
rate is 108/min, regularIntegumentary: Laceration noted to the client's left
hand (2 cm x 2.5 cm). Laceration noted to the left forearm (4 cm x 6 cm).
Profuse bleeding noted. Multiple small lacerations noted to face, left arm, and
right arm. Allergies: Unable to assess
Exhibit 2
Vital Signs
Day 1
1930:
Temperature 36.7° C (98.0° F)Pulse 108/minRespiratory rate 24/minBP
150/92 mm Hg1945:
P Correct Ans - For each potential assessment finding, click to specify
if the finding is consistent with schizophrenia or bipolar 1 disorder. Each
finding may support more than 1 disease process.
When analyzing cues, the nurse should distinguish between positive and
negative manifestations of schizophrenia and bipolar 1 disorder. The client is
displaying positive manifestations of schizophrenia, when compared to the
assessment findings of a client who has bipolar 1 disorder.
A nurse is caring for a client in an inpatient mental health facility.
,Exhibit 1
Medical HistoryClient is 44 years old, well-nourished, presenting with
recurrence of labile behavior involving self-mutilation, recent arrest for
reckless driving, stealing money from work for gambling debts, depressive
episodes, and binge eating.Provider's skin assessment reveals multiple
superficial self-inflicted lacerations to right arm.
Client plays golf three mornings per week.
Employed as salesperson at a car dealership for 8 years.
Exhibit 2
Nurses' Notes
Day 1
1500:
Client is talkative, well-groomed.
Expresses anxiety when left alone and states they would prefer a roommate.
The client tends to be the center of attention in the dayroom.
1600:
Client assigned a roommate.Day 2
1300:
Pacing for last hour and mumbling to self. Argued with staff earlier about
going to lunch in the cafeteria.
Glaring at staff members with fists clenche Correct Ans - Select the 2
findings from the client's medical record that are manifestations of borderline
personality disorder.
Behavior toward roommate
Skin assessment
When recognizing cues, the nurse should identify that the client's skin
assessment and behavior toward roommate are indications of borderline
personality disorder. Clients who have borderline personality disorder
display unstable relationships, labile moods, and impulsivity, such as
excessive spending, binging, substance abuse, and reckless driving. They also
have recurrent episodes of self-harm and might engage in suicidal actions.
They have difficulty controlling their anger and might have paranoid
ideations. They have chronic feelings of emptiness and do not like to be alone.
A nurse is assisting with the care of a client who is 1 day postoperative
following a total thyroidectomy.
Exhibit 1
, Laboratory ResultsDay 2, 0700:
Sodium 143 mEq/L (136 to 145 mEq/L)Potassium 3.5 mEq/L (3.5 to 5
mEq/L)Chloride 104 mEq/L (98 to 106 mEq/L)BUN 15 mg/dL (10 to 20
mg/dL)Magnesium 1.5 mEq/L (1.3 to 2.1 mEq/L)Total calcium 8 mg/dL (9 to
10.5 mg/dL)Phosphate 4.6 mg/dL (3 to 4.5 mg/dL)Glucose 95 mg/dL (74 to
106 mg/dL)WBC count 9,500/mm3 (5,000 to 10,000/mm3)
Exhibit 2
Nurses' Notes
Day 2, 0700:
Client alert and oriented x 3. Respirations even and unlabored with no
adventitious sounds. Bowel sounds active in all four quadrants. Surgical
dressing dry, slight edema at incision site noted. Client rates dull pain in neck
at 2 on a 0 to 10 scale. Declines pain medication.1100:
Client alert and oriented x 3. Respirations even and unlabored with no
adventitious sounds. Bowel sounds active in all four quadrants. Correct
Ans - Complete the following sentence by using the lists of options.
The client is at highest risk for developing
hypocalcemia
as evidenced by the
report of numbness around lips
The nurse should recognize cues and determine that the client is at highest
risk for developing hypocalcemia as evidenced by the client's report of muscle
spasms, numbness around lips, and decreased calcium level. Hypocalcemia is
more likely to occur in clients who have experienced a thyroidectomy, due to
accidental damage to the parathyroid. Numbness around the lips is a clinical
manifestation specific to hypocalcemia. Hypocalcemia presents as muscle
spasms and can lead to cardiac dysrhythmias. Hypocalcemia is the highest
priority, as it requires immediate treatment with calcium gluconate to avoid
dysrhythmias and other complications.
A nurse is assisting with the care of a client who has schizophrenia in an
inpatient facility.
Exhibit 1
Medication Administration Record
Day 1
0630:
Clozapine 100 mg PO dailyAripiprazole 5 mg PO dailyMultivitamin PO daily
& Verified Answers
A nurse is collecting data on a newborn who is 3 days old.
Exhibit 1
History and Physical
Newborn was delivered at 37 weeks gestation via cesarean section for fetal
distress.Apgar scores 8 at 1 min and 9 at 5 min.Birthweight 2,892 g (6 lb 6
oz)The client who gave birth plans to breastfeed.
Exhibit 2
Flow Sheet
Day 2 of Life
0900:
Temperature 36.7° C (98° F)Heart rate 140/minRespiratory rate
48/minWeight 2,718 g (6 lb), 6% weight lossDay 3 of Life
0800:
Temperature 36.4° C (97.5° F)Heart rate 140/minRespiratory rate
48/minWeight 2,545 g (5 lb 9 oz), 12% weight loss
Exhibit 3
Nurses' Notes
Day 3 of Life
0800:
Skin color consistent with newborn's genetic background. Respirations easy
and unlabored. Abdomen soft with active bowel sounds. Mild tremors noted
when awake. Anterior fontanel level and soft. Large ecchymotic caput
succedaneum noted on posterior scalp. Small amount of bloody mucus
discharge noted from vag Correct Ans - Click to highlight the findings
that require follow-up. To deselect a finding, click on the finding again.
Temperature 36.4° C (97.5° F)
Weight 2,545 g (5 lb 9 oz) 12% weight loss
Mild tremors noted when awake.
Breastfeeding every 3 to 5 hr for 5 to 10 min.
Birth parent reports nipple discomfort throughout the feeding.
,When recognizing cues, the nurse should identify that a temperature of 36.4°
C (97.5° F) is below the expected reference range. Hypothermia can lead to
the occurrence of hypoglycemia and respiratory distress. The newborn
breastfeeding for short intervals, nipple discomfort, and a weight loss of
greater than 10% of birth weight can indicate inadequate transfer of
breastmilk, which can result in hypoglycemia. The presence of mild tremors
can be a manifestation of hypoglycemia.
A nurse is assisting with the care of a client who was admitted to the
emergency department (ED).
Exhibit 1
Admission Assessment
Day 1
1930:
Client admitted to the ED by police after report of violent behavior in public.
Client smashed a glass window with their hands. Client is stating, "I am Jesus."
Client is attempting to hit staff. Client placed in restraints. Neuro: Client is
alert and oriented x 0. Client is swinging their arms and shouting. Client is
unable to answer questions and their speech is rapid and unorganized. Heart
rate is 108/min, regularIntegumentary: Laceration noted to the client's left
hand (2 cm x 2.5 cm). Laceration noted to the left forearm (4 cm x 6 cm).
Profuse bleeding noted. Multiple small lacerations noted to face, left arm, and
right arm. Allergies: Unable to assess
Exhibit 2
Vital Signs
Day 1
1930:
Temperature 36.7° C (98.0° F)Pulse 108/minRespiratory rate 24/minBP
150/92 mm Hg1945:
P Correct Ans - For each potential assessment finding, click to specify
if the finding is consistent with schizophrenia or bipolar 1 disorder. Each
finding may support more than 1 disease process.
When analyzing cues, the nurse should distinguish between positive and
negative manifestations of schizophrenia and bipolar 1 disorder. The client is
displaying positive manifestations of schizophrenia, when compared to the
assessment findings of a client who has bipolar 1 disorder.
A nurse is caring for a client in an inpatient mental health facility.
,Exhibit 1
Medical HistoryClient is 44 years old, well-nourished, presenting with
recurrence of labile behavior involving self-mutilation, recent arrest for
reckless driving, stealing money from work for gambling debts, depressive
episodes, and binge eating.Provider's skin assessment reveals multiple
superficial self-inflicted lacerations to right arm.
Client plays golf three mornings per week.
Employed as salesperson at a car dealership for 8 years.
Exhibit 2
Nurses' Notes
Day 1
1500:
Client is talkative, well-groomed.
Expresses anxiety when left alone and states they would prefer a roommate.
The client tends to be the center of attention in the dayroom.
1600:
Client assigned a roommate.Day 2
1300:
Pacing for last hour and mumbling to self. Argued with staff earlier about
going to lunch in the cafeteria.
Glaring at staff members with fists clenche Correct Ans - Select the 2
findings from the client's medical record that are manifestations of borderline
personality disorder.
Behavior toward roommate
Skin assessment
When recognizing cues, the nurse should identify that the client's skin
assessment and behavior toward roommate are indications of borderline
personality disorder. Clients who have borderline personality disorder
display unstable relationships, labile moods, and impulsivity, such as
excessive spending, binging, substance abuse, and reckless driving. They also
have recurrent episodes of self-harm and might engage in suicidal actions.
They have difficulty controlling their anger and might have paranoid
ideations. They have chronic feelings of emptiness and do not like to be alone.
A nurse is assisting with the care of a client who is 1 day postoperative
following a total thyroidectomy.
Exhibit 1
, Laboratory ResultsDay 2, 0700:
Sodium 143 mEq/L (136 to 145 mEq/L)Potassium 3.5 mEq/L (3.5 to 5
mEq/L)Chloride 104 mEq/L (98 to 106 mEq/L)BUN 15 mg/dL (10 to 20
mg/dL)Magnesium 1.5 mEq/L (1.3 to 2.1 mEq/L)Total calcium 8 mg/dL (9 to
10.5 mg/dL)Phosphate 4.6 mg/dL (3 to 4.5 mg/dL)Glucose 95 mg/dL (74 to
106 mg/dL)WBC count 9,500/mm3 (5,000 to 10,000/mm3)
Exhibit 2
Nurses' Notes
Day 2, 0700:
Client alert and oriented x 3. Respirations even and unlabored with no
adventitious sounds. Bowel sounds active in all four quadrants. Surgical
dressing dry, slight edema at incision site noted. Client rates dull pain in neck
at 2 on a 0 to 10 scale. Declines pain medication.1100:
Client alert and oriented x 3. Respirations even and unlabored with no
adventitious sounds. Bowel sounds active in all four quadrants. Correct
Ans - Complete the following sentence by using the lists of options.
The client is at highest risk for developing
hypocalcemia
as evidenced by the
report of numbness around lips
The nurse should recognize cues and determine that the client is at highest
risk for developing hypocalcemia as evidenced by the client's report of muscle
spasms, numbness around lips, and decreased calcium level. Hypocalcemia is
more likely to occur in clients who have experienced a thyroidectomy, due to
accidental damage to the parathyroid. Numbness around the lips is a clinical
manifestation specific to hypocalcemia. Hypocalcemia presents as muscle
spasms and can lead to cardiac dysrhythmias. Hypocalcemia is the highest
priority, as it requires immediate treatment with calcium gluconate to avoid
dysrhythmias and other complications.
A nurse is assisting with the care of a client who has schizophrenia in an
inpatient facility.
Exhibit 1
Medication Administration Record
Day 1
0630:
Clozapine 100 mg PO dailyAripiprazole 5 mg PO dailyMultivitamin PO daily
