Question

A client is admitted following a motor vehicle collision. When assessing the client's level of consciousness, the nurse notes that the client no longer responds to commands. The nurse initiates a painful stimulus and the client responds by pulling the arms inward with elbows and wrists flexed and extending the legs with the toes pointed downward. Which action should the nurse implement?

Answer 1

Correct Answers:

Report the finding to the healthcare provider.

Rationale :

🟦 The client’s response to painful stimuli demonstrates decorticate posturing, characterized by flexion of the upper extremities and extension of the lower extremities, which indicates severe neurologic impairment.

🟦 This motor response reflects worsening level of consciousness and possible increased intracranial pressure (ICP) following traumatic brain injury.

🟦 Decorticate posturing is a non-purposeful response and signals acute neurologic deterioration, requiring immediate medical evaluation.

🟦 Promptly reporting this finding allows for rapid diagnostic imaging, escalation of care, and timely interventions to prevent secondary brain injury.

🟦 Early provider notification supports neuroprotective management, which is critical in trauma patients with declining neurologic status.

Document the purposeful response to pain

🟦 The observed motor response is not purposeful but represents abnormal neurologic posturing.

🟦 Mislabeling this finding could delay recognition of a life-threatening neurologic decline.

Administer a prescribed PRN analgesic

🟦 Pain medication does not address the underlying neurologic pathology causing the abnormal response.

🟦 Analgesics may obscure ongoing neurologic assessment and delay urgent intervention.

Initiate seizure precautions immediately

🟦 There are no clinical indicators of seizure activity in the assessment findings.

🟦 The priority is escalation of care for neurologic deterioration rather than preventive seizure measures.

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Answer 2

Correct Answers:

Take medication on an empty stomach.

Rationale :

🟦 Tetracycline is best absorbed when taken on an empty stomach, as food can significantly reduce its gastrointestinal absorption.

🟦 The presence of calcium, iron, magnesium, and aluminum interferes with tetracycline by forming insoluble complexes in the gut.

🟦 Reduced absorption can lead to subtherapeutic drug levels, decreasing the medication’s effectiveness in treating acne.

🟦 Taking the medication with a full glass of water while the stomach is empty maximizes bioavailability and therapeutic response.

🟦 This instruction supports consistent serum drug levels and optimal antibacterial action.

Take medication with a dairy product

🟦 Dairy products contain calcium, which binds to tetracycline and inhibits absorption.

🟦 This interaction significantly reduces the effectiveness of the medication.

Take medication before taking an iron product

🟦 Iron supplements strongly chelate tetracycline and prevent adequate absorption.

🟦 Even spacing doses too closely can still reduce therapeutic drug levels.

Take medication with a meal

🟦 Food delays gastric emptying and decreases tetracycline absorption.

🟦 This can result in lower plasma concentrations and reduced treatment efficacy.

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Answer 3

Correct Answers:

Reduced level of pain.

Rationale :

🟦 Pregabalin is prescribed to manage neuropathic pain by decreasing abnormal neuronal excitability associated with diabetic peripheral neuropathy.

🟦 An effective therapeutic response is evidenced by a decrease in pain intensity, such as reduced burning, tingling, or shooting sensations.

🟦 Pain relief can be observed within several days of initiation, making a reduced pain level an appropriate early indicator of effectiveness.

🟦 Improvement in pain supports enhanced functional ability and comfort, which are primary goals of neuropathic pain management.

🟦 This outcome confirms that the medication is achieving its intended analgesic effect on nerve-related pain.

Improved visual acuity

🟦 Pregabalin has no therapeutic action on visual pathways or ocular function.

🟦 Changes in vision are unrelated to its mechanism of action in neuropathic pain control.

Granulating tissue in foot ulcer

🟦 Wound healing reflects improved circulation and glycemic control rather than neuropathic pain management.

🟦 Pregabalin does not promote tissue regeneration or ulcer healing.

Full volume of pedal pulses

🟦 Pedal pulses indicate peripheral circulation, not nerve pain modulation.

🟦 Pregabalin does not improve arterial blood flow or vascular status.

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Answer 4

Correct Answers:

Halo around blood dropped on gauze.

Rationale :

🟦 A halo or ring sign around blood indicates the presence of cerebrospinal fluid (CSF) leakage, which strongly suggests a basilar skull fracture.

🟦 CSF rhinorrhea places the client at immediate risk for central nervous system infection, including meningitis.

🟦 This finding represents a neurologic emergency that requires rapid provider notification and protective interventions.

🟦 Immediate actions focus on preventing further CSF leakage, avoiding nasal manipulation, and preparing for diagnostic confirmation.

🟦 Early recognition allows timely implementation of neuroprotective and infection-prevention measures.

Blood pressure decreases to 110/64 mm Hg

🟦 This blood pressure remains within an acceptable range and does not indicate acute shock or instability.

🟦 It does not require immediate intervention compared with signs of skull fracture and CSF leakage.

Pupils 3 mm with sluggish response

🟦 Sluggish pupillary response suggests possible neurologic involvement but is not the most urgent finding.

🟦 The presence of CSF leakage takes priority due to infection risk.

Clots of blood forming within nares

🟦 Nasal clots are expected with facial trauma and active bleeding.

🟦 They are less critical than signs indicating a fracture of the skull base.

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Answer 5

Correct Answers:

Increasing confusion of the client.

Rationale :

🟦 In SBAR communication, the Situation is stated first and focuses on the immediate problem or change in the client’s condition.

🟦 Increasing confusion represents an acute change in mental status, which may indicate complications such as head injury, intracranial bleeding, or medication effects in an older adult.

🟦 Presenting this information first alerts the healthcare provider to a potentially urgent neurologic concern requiring prompt evaluation.

🟦 Early emphasis on the current problem supports rapid clinical decision-making and prioritization of diagnostic or therapeutic actions.

🟦 This approach ensures effective, concise communication that enhances patient safety and timely intervention.

Fall at home as reason for admission

🟦 This information belongs in the Background portion of SBAR, not the opening statement.

🟦 While relevant, it does not communicate the client’s current deterioration.

Currently prescribed medications

🟦 Medication history is part of the Background data provided after stating the situation.

🟦 It supports assessment but is not the most urgent information to communicate first.

Client's healthcare power of attorney

🟦 This is important administrative information but does not reflect the client’s immediate clinical status.

🟦 It should not precede reporting an acute change in condition.

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Answer 6

Correct Answers:

Neutrophil count.

Rationale :

🟦 Purulent drainage is a classic sign of infection, and the neutrophil count is the most direct laboratory indicator of an acute bacterial response.

🟦 Neutrophils are the primary white blood cells involved in phagocytosis and inflammation, rising early during infection.

🟦 An elevated neutrophil count supports clinical suspicion of a postoperative wound infection that requires prompt provider evaluation.

🟦 Correlating wound appearance with this value strengthens the accuracy of clinical reporting and urgency of intervention.

🟦 This information helps guide decisions regarding cultures, antibiotic therapy, and further wound management.

Hematocrit

🟦 Hematocrit reflects red blood cell concentration and oxygen-carrying capacity.

🟦 It does not provide information about infectious or inflammatory processes.

Serum sodium level

🟦 Sodium levels indicate fluid and electrolyte balance.

🟦 They are not specific markers for infection or wound complications.

Platelet count

🟦 Platelets are primarily involved in clotting and hemostasis.

🟦 Changes in platelet count do not directly indicate wound infection.

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Answer 7

Correct Answers:

Administer a prescribed albuterol inhaler.

Rationale :

🟦 The client’s shortness of breath and oxygen saturation of 88% indicate acute bronchoconstriction commonly seen in emphysema.

🟦 Albuterol is a short-acting bronchodilator that rapidly relaxes airway smooth muscle to improve airflow.

🟦 Administering the inhaler is an immediate intervention that can quickly relieve dyspnea and improve oxygenation.

🟦 The stable vital signs and adequate respiratory rate support initiating prescribed rescue therapy rather than delaying care.

🟦 Prompt bronchodilation enhances gas exchange and reduces work of breathing in clients with COPD exacerbations.

Encourage client to initiate a smoking cessation program

🟦 Smoking cessation is an important long-term goal but does not address the client’s current respiratory distress.

🟦 It is not appropriate as an immediate intervention for acute shortness of breath.

Assess lung sounds for signs of infection

🟦 Further assessment may be helpful but should not delay treatment of active bronchospasm.

🟦 There are no indicators such as fever or unstable vital signs suggesting infection as the priority problem.

Notify the healthcare provider of the low pulse oximetry value

🟦 The nurse should first implement an appropriate prescribed intervention within scope of practice.

🟦 Provider notification is indicated if the client fails to respond to initial treatment.

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Answer 8

Correct Answers:

Viral meningitis whose temperature changed from 101° F (38.3° C) to 102° F (38.9° C).

Rationale :

🟦 Viral meningitis is generally a stable and self-limiting neurologic condition, and a mild increase in temperature represents an expected, predictable change.

🟦 A low-grade to moderate fever is common in viral infections and can be managed with routine monitoring and prescribed antipyretics, which fall within the PN’s scope of practice.

🟦 The client does not exhibit signs of acute neurologic deterioration or life-threatening instability.

🟦 Assigning this client allows the RN to focus on clients with rapidly changing or critical neurologic status.

🟦 This delegation aligns with safe staffing principles by matching client stability with appropriate nursing skill level.

Myxedema coma with blood pressure changing from 80/50 mm Hg to 70/40 mm Hg

🟦 This reflects worsening hemodynamic instability and impending shock.

🟦 Such a critical endocrine and neurologic emergency requires immediate RN-level intervention.

Subdural hematoma with blood pressure changing from 150/80 mm Hg to 170/60 mm Hg

🟦 Rising systolic pressure with widening pulse pressure suggests increasing intracranial pressure.

🟦 This unstable neurologic change requires continuous RN assessment and rapid response.

Diabetic ketoacidosis with Glasgow Coma Scale score changing from 10 to 7

🟦 A declining GCS indicates acute neurologic deterioration.

🟦 This represents a life-threatening situation requiring advanced RN assessment and intervention.

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Answer 9

Correct Answers

Blank 1 Correct Option: Hyponatremia
Blank 2 Correct Option: Syndrome of inappropriate antidiuretic hormone

Rationale :

🟦 The presence of a hypothalamic tumor strongly supports disruption of antidiuretic hormone (ADH) regulation, leading to excessive water retention.

🟦 SIADH causes dilutional hyponatremia, which commonly manifests as confusion and altered level of consciousness, consistent with the client’s admitting symptoms.

🟦 The client’s progressive hypotension and tachycardia indicate intravascular fluid shifts rather than true volume loss.

🟦 Despite continuous IV fluids, the client exhibits abnormally high urine output, reflecting impaired sodium-water balance rather than dehydration.

🟦 These findings collectively support hyponatremia secondary to SIADH, a known complication of hypothalamic pathology.

Hypovolemia

🟦 Hypovolemia would present with reduced urine output and clinical signs of dehydration.

🟦 This client demonstrates excessive urine output with ongoing IV fluid administration.

Hyperkalemia

🟦 Hyperkalemia primarily affects cardiac and neuromuscular function.

🟦 There are no ECG changes or potassium-related symptoms presented.

Myxedema

🟦 Myxedema coma is associated with severe hypothyroidism, hypothermia, and bradycardia.

🟦 The client’s temperature and heart rate trends do not support this diagnosis.

Adrenal insufficiency

🟦 Adrenal insufficiency typically presents with hypotension and hyperkalemia.

🟦 There is no evidence of electrolyte imbalance consistent with cortisol deficiency.

Thyroid storm

🟦 Thyroid storm presents with hyperthermia, severe tachycardia, and agitation.

🟦 The client remains normothermic without signs of extreme metabolic acceleration.

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Answer 10

Correct Answers:

Tell the client in a matter-of-fact manner to stop the sexual advances.

Rationale :

🟦 The nurse’s first priority is to set clear professional boundaries to maintain a therapeutic and safe environment.

🟦 Addressing the behavior immediately helps stop inappropriate conduct before it escalates or disrupts care.

🟦 A calm, matter-of-fact response models assertive communication without shaming or engaging the behavior.

🟦 This approach reinforces unit expectations and protects both staff and clients.

🟦 Prompt limit-setting supports effective psychiatric nursing practice and preserves therapeutic rapport.

Request an immediate team meeting to discuss the inappropriate behavior

🟦 A team meeting may be helpful later but does not address the behavior in the moment.

🟦 Delaying action allows the inappropriate behavior to continue.

Document as specifically as possible the client's behavior in the nurse's notes

🟦 Documentation is important but should follow immediate limit-setting.

🟦 It does not stop the behavior when it occurs.

Discuss with the client why the client is making sexual advances toward the nurse

🟦 Exploring motives can inadvertently reinforce or prolong the behavior.

🟦 Boundary setting must occur before any therapeutic exploration.

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Intake and output (180)	IV fluid intake (mL)	Urine output (mL)
1600	100	89
1700	100	100
1800	100	450
1900	100	420

QLexNursing

2 :
A client receives a prescription for 250 mg of tetracycline PO every other day for acne. Which instruction should the nurse give regarding the best way to take the medication?

3 :
A client with diabetic peripheral neuropathy has been taking pregabalin for 4 days. Which finding indicates to the nurse that the medication is effective?

6 :
While changing a client's postoperative dressing, the nurse observes purulent drainage at the site. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

8 :
The charge nurse is making assignments for one practical nurse (PN) and three registered nurses (RN) who are caring for neurologically compromised clients. Which client with which change in status is best to assign to the PN?

9 :
The client is a 36-year-old female admitted for confusion and a change in level of consciousness.

Correct Answers

10 :
A client on the psychiatric unit is making sexual advances towards a nurse. Which action should this nurse implement first?

QLexNursing

2 : A client receives a prescription for 250 mg of tetracycline PO every other day for acne. Which instruction should the nurse give regarding the best way to take the medication?

3 : A client with diabetic peripheral neuropathy has been taking pregabalin for 4 days. Which finding indicates to the nurse that the medication is effective?

6 : While changing a client's postoperative dressing, the nurse observes purulent drainage at the site. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

8 : The charge nurse is making assignments for one practical nurse (PN) and three registered nurses (RN) who are caring for neurologically compromised clients. Which client with which change in status is best to assign to the PN?

9 : The client is a 36-year-old female admitted for confusion and a change in level of consciousness.

Correct Answers

10 : A client on the psychiatric unit is making sexual advances towards a nurse. Which action should this nurse implement first?

2 :
A client receives a prescription for 250 mg of tetracycline PO every other day for acne. Which instruction should the nurse give regarding the best way to take the medication?

3 :
A client with diabetic peripheral neuropathy has been taking pregabalin for 4 days. Which finding indicates to the nurse that the medication is effective?

6 :
While changing a client's postoperative dressing, the nurse observes purulent drainage at the site. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

8 :
The charge nurse is making assignments for one practical nurse (PN) and three registered nurses (RN) who are caring for neurologically compromised clients. Which client with which change in status is best to assign to the PN?

9 :
The client is a 36-year-old female admitted for confusion and a change in level of consciousness.

10 :
A client on the psychiatric unit is making sexual advances towards a nurse. Which action should this nurse implement first?