1 :

6 days ago:

Caregiver called clinic regarding their toddler. Caregiver states the toddler began experiencing watery diarrhea 1 day ago. The toddler has had 5 episodes of diarrhea over the past 24 hours. The toddler's temperature has been as high as 37.9°C (100.2°F). Caregiver instructed to increase the toddler's fluids, maintain normal diet, and monitor for signs of dehydration. Caregiver instructed to come to office if symptoms persist or worsen.

Today:

Toddler in office today with caregiver for evaluation of persistent diarrhea. Caregiver states the toddler is no experiencing bloody diarrhea and is complaining of a "hurt tummy." Caregiver reports the symptoms began a few days after eating an undercooked hamburger. Stool sample collected in office today and sent to laboratory for further evaluation.

Today:

Temperature 37.2°C (99°F)

Heart rate 110/min

Respiratory rate 29/min

Oxygen saturation 98% on room air


Complete the following sentence by using the lists of options. The client is at risk for due to


Hint : 🍔 Bloody diarrhea after burger = E. coli → HUS risk

Correct Answers

  • Blank 1 Correct Option: hemolytic uremic syndrome
  • Blank 2 Correct Option: Escherichia coli infection

Rationale :

💎 The toddler’s bloody diarrhea following ingestion of undercooked hamburger strongly suggests infection with Shiga toxin–producing Escherichia coli (E. coli O157:H7).

💎 A major complication of this infection is Hemolytic Uremic Syndrome (HUS), characterized by hemolytic anemia, thrombocytopenia, and acute renal failure.

💎 HUS primarily affects young children and develops days after the onset of bloody diarrhea.

💎 The nurse should closely monitor urine output, pallor, edema, and signs of renal impairment (elevated BUN and creatinine).

💎 Early recognition and supportive management (hydration, monitoring labs, avoiding antibiotics and antidiarrheals) are critical to prevent kidney failure.


Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

2 :

0800:

Client sustained laceration to left shin. Wound edges well approximated. Bandage placed over laceration. Client alert and oriented, gait steady. Heart rate 881min, respiratory rate 20/min.

0815:

Scant amount of serosanguinous drainage visible through client's bandage.

Client 2
0800:

Client sustained deep partial thickness burns over 10% of total body surface area. Client alert and oriented. Heart rate 102/min respiratory rate 221min, blood pressure 110/70 mm Hg.

0805:

Client states “l need something for this pain, it's unbearable." Client diaphoretic. heart rate 1 15/min, respiratory rate 26/min, blood pressure 98/62 mm Hg.

Client 3

0800:

Client sustained blunt force injury to forehead. Edema present over left side of forehead, tender to touch. skin intact. Client is alert and oriented. Heart rate 90/min, respiratory rate 18/min.

0810:

Client is alert and oriented. Client reports mild headache over frontal region of forehead. Pupils equal, round, reactive to light, accommodate. Heart rate 88/min, respiratory rate 19/min.

Client 4

0800:

Client sustained severe injury to head and cervical spine. Client is unconscious. pupils fixed, respirations are shallow.

0805:

Client remains unconscious, pupils fixed, decorticate posturing present, respirations irregular and shallow.

Client 5 
0800:

Client has open fracture of left forearm. Client is alert and oriented. Radial pulses 2+ bilaterally. Heart rate 95fmin, respiratory rate 17/min.

0810:

Client reports a pain level of 8 on a 0 to 10 pain scale.

Client 6

0800:

Client states “l inhaled a lot of smoke during the explosion." Client is seated upright. Lungs clear to auscultation bilaterally. Heart rate 97/min, respiratory rate 21/min.

0815:

Client seated in tripod position, appears anxious. Breath sounds diminished, intercostal retractions visible. Heart rate 102/min, respiratory rate 27/min.


Select the 2 clients that the nurse should identify as requiring immediate care.


Answer Options

Hint : 🚨 Unconscious + breathing changes OR airway distress = immediate priority

Correct Answers:

  • Client 4
  • Client 6


Rationale :

💎 Client 4 — Severe head and cervical spine injury The client is unconscious with fixed pupils and later exhibits decorticate posturing and irregular, shallow respirations, all of which indicate increased intracranial pressure (ICP) and brainstem involvement.

💎These are life-threatening neurologic and respiratory findings requiring immediate stabilization of airway and cervical spine.

💎Priority actions: Maintain airway, provide oxygen, prepare for possible intubation, and immobilize cervical spine.

💎This client is a Red Tag (Immediate) priority under disaster triage principles.

💎 Client 6 — Smoke inhalation injury

💎Initially stable, but now has diminished breath sounds, intercostal retractions, tripod position, and anxiety, showing impending airway obstruction from inhalation injury or edema.

💎Rapid deterioration of oxygenation and ventilation makes this client a critical airway emergency.

💎Priority actions: Secure airway, administer high-flow oxygen, prepare for intubation before respiratory failure occurs.

Also classified as Red Tag (Immediate).

💎Client 2: Pain and mild hypotension from burns (Yellow Tag – Delayed).

💎Client 1: Minor laceration (Green Tag – Minimal).

💎Client 3: Stable head contusion, alert (Green Tag – Minimal).

💎Client 5: Open fracture with stable circulation (Yellow Tag – Delayed).


Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

3 :

Hint : 🔷 Writing = acceptance and peace

Correct Answers:

  • The client journals about the experience of dying.


Rationale :

💎 Journaling is a constructive coping mechanism that helps clients express and process emotions about death.

💎 It allows for self-reflection and acceptance, indicating movement toward the acceptance stage of grief.

💎 Writing can reduce anxiety and fear associated with terminal illness.

💎 This action shows the client is addressing their reality rather than avoiding it.

💎 It supports emotional healing and psychological preparation for end-of-life.


Distractor Analysis :

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4 :

Hint : 💙Side vision loss = glaucoma

Correct Answers:

  • “I have to turn my head completely to see things that are beside me."


Rationale :

💎 This indicates peripheral vision loss, commonly associated with glaucoma.

💎 Glaucoma causes gradual loss of side vision, often unnoticed until advanced.

💎 It requires immediate ophthalmologic evaluation to prevent blindness.

💎 The other statements indicate normal age-related adaptations.

💎 Early detection prevents optic nerve damage.


Distractor Analysis :

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5 :

Hint : 🩺 Screening = secondary prevention

Correct Answers:

  • Performing hypertension screenings in a community center


Rationale :

💎 Secondary prevention focuses on early detection and treatment of disease.

💎 Screening identifies conditions before symptoms occur.

💎 This reduces progression and complications of disease.

💎 Hypertension screening helps initiate early lifestyle or medical interventions.

💎 This action fits the “detect and treat early” principle of secondary prevention.


Distractor Analysis :

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6 :

Hint : 🎀Quitting = early intervention

Correct Answers:

  • Provide a smoking cessation class.


Rationale :

💎 Secondary prevention involves actions that identify and treat early signs of illness or risk behaviors.

💎 Smoking cessation helps prevent progression of early lung or heart disease.

💎 It is an intervention after risk exposure, not just prevention.

💎 It decreases morbidity and mortality from chronic illnesses.

💎 This is an example of behavioral modification for disease control.


Distractor Analysis :

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7 :

Hint : 💳 Fixed pay = HMO model

Correct Answers:

  • The provider is paid a fixed sum for the client on a monthly or yearly basis.


Rationale :

💎 A Health Maintenance Organization (HMO) uses a capitation payment model.

💎 Providers are paid a set fee per client, regardless of number of visits.

💎 Encourages preventive care to reduce long-term costs.

💎 Focuses on health maintenance rather than illness treatment.

💎 Promotes cost efficiency and coordinated care.


Distractor Analysis :

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8 :

Hint : 🌷 Comfort = palliative goal

Correct Answers:

  • “Palliative care aims to improve my quality of life."


Rationale :

💎 Palliative care focuses on symptom relief and comfort, not curing illness.

💎 It can begin at any stage of serious illness, not just at end-of-life.

💎 Supports physical, emotional, and spiritual needs.

💎 Involves interdisciplinary collaboration for holistic care.

💎 Enhances dignity and autonomy for patients and families.


Distractor Analysis :

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9 :

Hint : 👓 Cover one eye = alignment check

Correct Answers:

  • “Focus on the finger I am holding up while I cover one eye, and then the other.”


Rationale :

💎 This describes the cover test, used to assess ocular alignment and strabismus.

💎 The nurse observes eye movement of the uncovered eye as the other is covered.

💎 If the uncovered eye moves, deviation or misalignment exists.

💎 Tests binocular vision and muscle coordination.

💎 Essential for early detection of lazy eye (amblyopia) in children.


Distractor Analysis :

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10 :

Hint : 👶 Fear, poverty, and addiction = red flags

Correct Answers:

  • One of the child's parents appears frightened of the other parent.
  • Neither of the child's parents are financially stable.
  • One of the child's parents has d history of alcohol use disorder.


Rationale :

💎 A parent showing fear toward their partner suggests domestic violence, which increases the risk for child abuse in the household.

💎 Financial instability is a major social stressor that can contribute to neglect or physical abuse.

💎 A parental history of substance or alcohol use disorder correlates with impaired judgment and poor coping, raising the likelihood of child maltreatment.

💎 Multiple fractures in various stages of healing may be indicative of repeated trauma and warrant investigation.

💎 The nurse should report suspected abuse according to mandatory reporting laws.


Distractor Analysis :

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Total Questions: 10

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