PN Comprehensive Online Practice
Question and answers already passed
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 answer 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 answer 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:
Question and answers already passed
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 answer 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 answer 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:
