The nurse is assessing a 4-year-old child during a well-chil…

The nurse is assessing a 4-year-old child during a well-child visit. The parent reports that the child rarely responds to their name, avoids back-and-forth play, becomes extremely upset when the daily routine changes, lines up toys repeatedly, and covers their ears when the vacuum is turned on. Which interpretation by the nurse is most appropriate?

The nurse is preparing to start an enteral feeding for Mr. A…

The nurse is preparing to start an enteral feeding for Mr. Alvarez, a 68-year-old patient with dysphagia after a stroke. The provider has prescribed continuous tube feeding through an ENFit-compatible feeding tube. Before initiating the feeding, the nurse reviews the enteral feeding bag, tubing, and formula label. Which label information is most important for the nurse to verify to promote safe enteral nutrition administration?

The nurse is turning a patient who has been immobile after s…

The nurse is turning a patient who has been immobile after surgery. The nurse notices a purple-maroon area over the right hip. The skin is intact, but the area feels boggy and warmer than the surrounding tissue. A small blood-filled blister is also present. Which label best describes this finding?

A 9-year-old child who speaks limited English is brought to…

A 9-year-old child who speaks limited English is brought to the emergency department with bruising. The caregiver answers all questions for the child. The child appears anxious and avoids eye contact. The nurse needs to assess the child further. What is the nurse’s priority communication action?

The nurse is caring for a patient whose spouse died earlier…

The nurse is caring for a patient whose spouse died earlier in the day. The patient says, “If only I had made the appointment sooner, maybe this would not have happened. I keep thinking I should have done something different.” Which grief response is the patient demonstrating?

The nurse is completing a school health assessment for a 9-y…

The nurse is completing a school health assessment for a 9-year-old child. The teacher reports that the child frequently leaves the seat, interrupts classmates, loses assignments, and cannot stay organized. The parent reports that the child also becomes very upset when the daily routine changes, has intense sensory reactions to loud sounds, avoids reciprocal conversation, and has a restricted interest in train schedules. The child’s grades are declining, and the parent says, “I think he is just being defiant.” Which nursing response is most appropriate?

The nurse is providing discharge teaching to Ms. Reynolds, a…

The nurse is providing discharge teaching to Ms. Reynolds, a 58-year-old patient newly diagnosed with type 2 diabetes and hypertension. She states, “I know I need to eat better, but I get overwhelmed at the grocery store. I do not understand food labels, and I usually just buy whatever says ‘healthy’ on the front.” Her BMI is 31 kg/m², blood pressure is 148/88 mmHg, and her fasting blood glucose remains elevated. She also reports eating fast food several times per week and rarely exercising. Which nursing response best supports effective nutrition education?

The nurse is caring for a 6-week-old infant with an unrepair…

The nurse is caring for a 6-week-old infant with an unrepaired cleft palate. The parent reports that feedings take 55 minutes, formula leaks from the infant’s nose, and the infant coughs during feeds. The infant has gained only 3 ounces in the past 2 weeks. During the feeding observation, the nurse notes poor latch, frequent fatigue, and mild intercostal retractions after coughing. Which nursing action is the priority?

The nurse is caring for a 9-year-old child newly diagnosed w…

The nurse is caring for a 9-year-old child newly diagnosed with type 1 diabetes. The child says, “I am never going to be able to do this. Everyone else at school is normal.” The parent asks how to help the child cope. Which nursing intervention best supports this child’s Erikson stage?