the emergency department charge nurse is reviewing the clients triaged in the last 30 minutes the nurse is required to obtain a social service consult the emergency department charge nurse is reviewing the clients triaged in the last 30 minutes the nurse is required to obtain a social service consult
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Nursing Elites

NCLEX NCLEX-PN

NCLEX Question of The Day

1. The emergency department charge nurse is reviewing the clients triaged in the last 30 minutes. The nurse is required to obtain a social service consult from which of the following clients?

Correct answer: A 6-year-old who drank some diluted bleach.

Rationale: For children under 7 years, most states have laws that mandate reporting certain situations to social services or child protection, such as ingestions of toxic substances, fractures, suspected neglect, or abuse, and burns. In this scenario, the 6-year-old who drank diluted bleach falls under the category that requires a social service consult. The other choices involve injuries or conditions that may warrant medical attention but do not necessarily mandate a social service consult based on age-related legal requirements.

2. A client sitting alone and talking to voices is observed by a nurse. When asked, the client reports he is 'talking to the voices.' The nurse’s next action should be:

Correct answer: asking the client to describe what is happening

Rationale: When a client reports talking to voices, it can indicate the presence of hallucinations. Asking the client to describe what is happening is a crucial step as it helps the nurse understand the nature of the hallucinations and provides reassurance to the client. Touching the client without consent is inappropriate and can be distressing. Leaving the client alone may not address the underlying issue, and telling the client there are no voices denies their experience and can lead to mistrust.

3. A 6-year-old with cerebral palsy functions at the level of an 18-month-old. Which finding would support that assessment?

Correct answer: She pulls a toy behind her

Rationale: The correct answer is 'She pulls a toy behind her.' This behavior is consistent with the developmental stage of an 18-month-old who enjoys push-pull toys. Dressing oneself usually begins around 3 years old, building a tower of eight blocks at approximately 3 years old, and copying a horizontal or vertical line at about 4 years old. Choices A, C, and D are incorrect as they represent skills that are typically observed in older children.

4. The nurse is obtaining a health assessment from the preoperative client scheduled for hip replacement surgery. Which statement by the client would be most important for the nurse to report to the physician?

Correct answer: “I had rheumatic fever when I was 10 years old.”

Rationale: The most important statement for the nurse to report to the physician is that the client had rheumatic fever when they were 10 years old. This information is crucial as individuals who have had rheumatic fever require pre-medication with antibiotics before any surgical or dental procedure to prevent bacterial endocarditis. Reporting this history ensures the client's safety during the hip replacement surgery. The other options, such as having chickenpox in the past, a family history of gastric cancer, or experiencing hip pain, are important for the client's overall health assessment but do not have the same immediate implications for the upcoming surgery as the history of rheumatic fever.

5. The LPN receives a call from a mother caring for her eight-month-old infant. The mother describes that the child has a low-grade fever and has teeth breaking through the gums. Which of the following measures would be inappropriate to recommend to the mother?

Correct answer: Administer aspirin.

Rationale: Administering aspirin would be inappropriate in this situation. Aspirin should not be recommended for children due to the increased risk of Reye’s syndrome, a serious condition. Choices A, B, and C are all appropriate measures for managing teething discomfort in infants. Allowing the child to chew on a cooled teething ring can help soothe the gums, massaging the child's gums gently can provide relief, and administering acetaminophen is a suitable option for pain relief in infants with teething discomfort. Aspirin is contraindicated in children with viral infections due to the risk of Reye's syndrome, a potentially fatal condition affecting the brain and liver. Therefore, recommending aspirin to the mother would not be appropriate in this case.

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