PN 2.0 Clinical Judgment Practice 2

A nurse in a clinic is caring for an infant at the 6-month well-child visit. Exhibit 1 Exhibit 2 Exhibit 3 Select the 4 findings that require immediate follow-up. - Head circumference - Heart rate - Inability to pick up objects - Head lag - Irritability - Fontanel findings - VP shunt line - Respiratory rate

- Head circumference - Fontanel findings - Head lag - Irritability

A nurse is caring for a child in a prenatal clinic. Exhibit 1 Exhibit 2 Exhibit 3 Exhibit 4 Drag 1 condition and 1 client finding to fill in each blank in the following sentence. The client is at risk for developing ____________ due to ____________.

- At risk for developing: preeclampsia - Due to: blood pressure

A nurse is caring for an infant in a clinic. Exhibit 1 Exhibit 2 Drag words from the choices below to fill in each blank in the following sentence. The nurse should follow up on _____________ and ______________. - BP - Temp - Weight - Heart rate - Verbal skills - Height - Respiratory rate - Fine motor skills - Gross motor skills

- Gross motor skills - Verbal skills

A nurse on a medical surgical floor is caring for a newly admitted client following a motor vehicle crash. Exhibit 1 Exhibit 2 Exhibit 3 Exhibit 4 Which of the following actions should the nurse take? Select all that apply. - Provide a stimulating environment for the client. - Delegate to have an AP in the room. - Report the client's behavior to the provider. - Request a prescription for lorazepam. - Assess the client's history of alcohol use. - Offer orange juice to the client. - Keep the room dark. - Implement seizure precautions.

- Implement seizure precautions - Assess the client's history of alcohol use - Delegate to have an AP in the room - Report the client's behavior to the provider - Offer orange juice to the client - Request a prescription for lorazepam

A nurse is caring for a client who is newly admitted to the hospital. Exhibit 1 Exhibit 2 Exhibit 3 Exhibit 4 Complete the following sentence by using the list of options. The nurse should first _______________ followed by ________________.

- Increase Oxygen - Administer a bronchodilator

A nurse is caring for a client in a clinic. Exhibit 1 Exhibit 2 Exhibit 3 Exhibit 4 Exhibit 5 Click to highlight the information the nurse should include in the educational material for the client. To deselect information, click on the information again. - Limit sodium intake to less than 1,500 mg/day - Walk daily at least 30 min - Limit cholesterol intake to 500 mg/day - Monitor blood pressure daily - Discuss options to eliminate tobacco use - Saturated fats should be not more than 10% of daily calorie intake - Take medication every morning before breakfast

- Limit sodium intake to less than 1,500 mg/day - Walk daily at least 30 min - Monitor blood pressure daily - Discuss options to eliminate tobacco use

A nurse is caring for a client in a clinic. Exhibit 1 Complete the following sentence by using the list of options. The nurse should first evaluate the client's ______________ as evidenced by the client's ____________________.

- risk for harming themselves - report of hopelessness

A nurse is caring for a newly admitted 2-year-old toddler. Exhibit 1 Exhibit 2 Exhibit 3 Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Actions to take: - Prepare the toddler for an MRI of the abdomen - Monitor Vital signs every hour Condition: - Wilm's tumors Parameter to Monitor: - Hypertension - Manifestation of anemia