Clinical Nursing Fundamental Exam

Correct Answer : The patient will identify spiritual supports available to her in this medical center

Explanation of the Correct Answer:

The patient's primary concern is feeling isolated from her family, church, and God while in the medical center.

The best goal is to help her find spiritual resources and support within the hospital that can provide comfort and connection, such as chaplains, support groups, or faith-based services.

This addresses her immediate distress by ensuring she has access to spiritual and emotional support even while she is far from home.

Explanation of Incorrect Answers:

The patient will express satisfaction with the compatibility of her spiritual beliefs and everyday living

This does not directly address her current distress about isolation but instead focuses on the long-term integration of spirituality into her daily life.

The patient will identify spiritual beliefs that meet her need for meaning and purpose.

While understanding her spiritual beliefs is important, her current concern is about disconnection from her religious community, not about defining her beliefs.

The patient will express peaceful acceptance of limitations and failings.

This assumes she needs to accept limitations, which may not be her primary struggle. Instead, she is seeking connection and support, not necessarily struggling with self-acceptance.

Summary:

The best goal (option d) helps the patient reconnect with spiritual support within the hospital, directly addressing her feelings of isolation. The other options do not specifically target her immediate need for connection.

The correct answer is A: chicken broth with Jell-O and coffee.

Explanation of the Correct Answer:

A clear liquid diet consists of liquids that are transparent and leave no residue in the gastrointestinal tract. These foods help maintain hydration and provide some nutrients while being easy to digest. Chicken broth, Jell-O, and coffee all meet the criteria for a clear liquid diet because they are fully liquid at body temperature and do not contain solids or pulp.

Explanation of Incorrect Answers:

A) Vegetable broth with yogurt and apple juice – Incorrect

Vegetable broth is acceptable on a clear liquid diet.

Yogurt is not a clear liquid; it is a dairy product and contains solids.

Apple juice is acceptable only if it is pulp-free. If it contains pulp, it does not qualify.

C) Chicken noodle soup with Pedialyte and tea – Incorrect

Chicken noodle soup is not a clear liquid because it contains solid components like chicken and noodles.

Pedialyte is an appropriate choice because it is a clear electrolyte solution.

​​​​​​​Tea is also acceptable, but the presence of chicken noodle soup disqualifies the entire meal from being considered clear liquid.

D) Tomato soup with a popsicle and water – Incorrect

Tomato soup is not a clear liquid because it is thick and often contains pulp or puree.

Popsicles are acceptable only if they are made from clear liquids without dairy or fruit pulp.

​​​​​​​Water is always acceptable but does not make the full meal compliant.

Summary:

A clear liquid diet consists only of transparent, easily digestible liquids. The correct meal choice is chicken broth, Jell-O, and coffee because they meet the dietary restrictions. The incorrect options contain items like yogurt, chicken noodle soup, and tomato soup, which are not classified as clear liquids.

Correct Answer:

A. Bleeding at the surgical site.

Why This Answer Is Correct:

Frequent swallowing after a tonsillectomy is a key sign of post-operative bleeding, especially in the back of the throat. Since the patient is often lying down, blood can pool in the throat, leading to silent bleeding that is noticed only when the patient swallows repeatedly.

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  Post-tonsillectomy hemorrhage is a medical emergency and requires immediate evaluation to prevent significant blood loss and airway obstruction.

  
  

Why the Other Answers Are Incorrect:

Option B: Normal healing process – Incorrect

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  Some discomfort and mild swelling are normal after a tonsillectomy, but frequent swallowing is not a normal healing sign—it suggests active bleeding.

  
  

Option C: Dehydration – Incorrect

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  Dehydration can occur post-surgery, but it would not cause frequent swallowing. Instead, it would present as dry mouth, reduced urine output, and lethargy.

  
  

Option D: Pain relief from anesthesia wearing off – Incorrect

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  As anesthesia wears off, patients may experience pain, but this would not cause frequent swallowing. Instead, the patient would likely report throat discomfort or pain while swallowing rather than an increased swallowing reflex.

  
  

Summary:

Frequent swallowing after a tonsillectomy is an early warning sign of bleeding at the surgical site. This can be life-threatening and requires immediate medical attention to assess for post-tonsillectomy hemorrhage and prevent complications.

Correct Answer: Over most of the peripheral lung fields.

Explanation of the Correct Answer:

Vesicular breath sounds are normal breath sounds heard over most of the lung fields, particularly in the peripheral areas (lungs' bases and lateral regions).

They are soft and low-pitched with a longer inspiratory phase than the expiratory phase.

These sounds occur when air moves through smaller airways, including the bronchioles and alveoli.

Explanation of Incorrect Answers:

Option A: Over the trachea and main bronchi – Incorrect

Bronchial breath sounds, not vesicular sounds, are heard over the trachea and mainstem bronchi.

Bronchial sounds are louder and higher-pitched than vesicular sounds.

Option C: Over the sternum and upper anterior chest – Incorrect

Bronchovesicular breath sounds, not vesicular sounds, are heard over the sternum and upper anterior chest.

These are medium-pitched and have equal inspiratory and expiratory phases.

Option D: Only at the bases of the lungs – Incorrect

Vesicular sounds are heard throughout most of the lung fields, not just the bases.

While they are present at the lung bases, they also extend to the lateral and posterior lung regions.

Summary:

Vesicular breath sounds are soft, low-pitched breath sounds heard over most of the lung's peripheral areas, including the bases and lateral lung fields. They indicate normal airflow through the small bronchioles and alveoli.

Correct Answer  B: Assess the patient.

Explanation:

The priority action in this situation is to assess the patient for injuries before taking any other steps. Falls can lead to serious injuries such as fractures, head trauma, or internal bleeding, so the nurse must first evaluate the patient's condition to determine the next course of action.

Why the Other Options Are Incorrect:

A) Place the patient on fall precautions. – Not the first action

While fall precautions are important, the priority is patient safety and injury assessment.

Fall precautions should be implemented after assessing the patient and ensuring their stability.

C) File a safety event report.– Not the priority

Incident reporting is important for documentation and quality improvement, but it should be done after the patient is assessed and safely repositioned.

D) Get the patient back to bed. – Risky without assessment

Moving the patient before assessing for injuries could worsen an undiagnosed fracture, spinal injury, or head trauma.

If the patient is unconscious or in distress, additional medical interventions may be required before repositioning.

Best Nursing Action (Step-by-Step):

Assess the patient for injuries (vital signs, level of consciousness, pain, mobility).

Call for assistance if needed (e.g., if the patient is unconscious or has a possible fracture).

Safely assist the patient back to bed if no serious injuries are present.

Notify the provider and implement fall precautions (e.g., bed alarms, assistive devices, lowering bed height).

Document the incident and file a safety report as per hospital policy.

Key Takeaway:

Always assess the patient first after a fall to determine their condition before taking further actions.

Correct Answe  C: Anticipating the scheduling of polysomnography to confirm OSA.

Explanation of the Correct Answer:

The child’s symptoms of snoring and labored breathing during sleep suggest the possibility of obstructive sleep apnea (OSA).

Polysomnography (sleep study) is the gold standard for diagnosing OSA. This test monitors brain activity, oxygen levels, heart rate, and breathing patterns during sleep.

OSA in children can result from enlarged tonsils and adenoids, obesity, or other airway abnormalities. If left untreated, it can lead to daytime sleepiness, learning difficulties, and cardiovascular complications.

Explanation of the Incorrect Answers:

Option a: Preparing the family for a diagnosis of insomnia and related treatments.

Insomnia refers to difficulty falling or staying asleep, not snoring and labored breathing.

The child’s symptoms do not align with insomnia since the concern here is abnormal breathing patterns rather than difficulty sleeping.

Option b: Preparing the family for a diagnosis of narcolepsy and related treatments.

Narcolepsy is a neurological disorder that causes excessive daytime sleepiness, sudden sleep attacks, and cataplexy (muscle weakness triggered by emotions).

​​​​​​​The child’s symptoms of snoring and labored breathing do not fit narcolepsy, making this answer incorrect.

Option d: No action would be taken, as this is a normal finding for hospitalized children.

Snoring and labored breathing are not normal in children and could indicate a serious sleep disorder such as OSA.

​​​​​​​Ignoring these symptoms could result in delayed diagnosis and complications such as poor oxygenation, cognitive impairments, and cardiovascular risks.

Summary:

​​​​​​​The child’s snoring and labored breathing suggest a potential diagnosis of obstructive sleep apnea (OSA), which requires polysomnography (sleep study) for confirmation. Other conditions such as insomnia or narcolepsy do not match the child’s symptoms, and ignoring the symptoms is not appropriate.

Correct Answers:

A: Teach the parents to reinforce their child's positive qualities.

C: Teach parents to ignore neutral behavior that is a matter of personal preference.

F: Teach parents to let their children practice skills and make it safe to fail.

Explanation of Correct Answers:

A: Teach the parents to reinforce their child's positive qualities.

Correct because positive reinforcement helps children recognize and appreciate their strengths.

Acknowledging positive qualities boosts self-worth and self-esteem.

C: Teach parents to ignore neutral behavior that is a matter of personal preference.

Correct because not every behavior requires intervention.

Allowing children to express themselves in harmless ways (e.g., clothing choices, hobbies) helps them develop autonomy and confidence.

F: Teach parents to let their children practice skills and make it safe to fail.

Correct because learning new skills and experiencing failure in a safe environment helps build resilience and self-esteem.

Encouraging children to try again after failure fosters a growth mindset and self-confidence.

Why the Other Options Are Incorrect:

B: Teach the parents to overlook occasional negative behavior.

Incorrect because negative behavior should not be ignored.

Instead of overlooking, parents should guide their children by setting clear expectations and using constructive discipline.

D: Teach parents to listen and "fix things" for their children.

Incorrect because self-esteem develops when children solve their own problems.

Parents should listen and support rather than fix everything, as problem-solving builds confidence and independence

E: Teach parents to describe the child's behavior and judge it.

Incorrect because judging a child’s behavior can lead to shame and insecurity.

Instead, parents should provide feedback without personal criticism, focusing on helping the child improve.

Final Summary:

​​​​​​​To build self-esteem, parents should reinforce positive qualities, allow self-expression, and create a safe space for learning and failure. Overlooking negative behavior, fixing problems for the child, or using judgmental language can hinder self-esteem development.

Correct Answer: Nonverbal children aged 2 months to 7 years.

Explanation of the Correct Answer:

The FLACC scale (Face, Legs, Activity, Cry, Consolability) is a behavioral pain assessment tool designed for infants and young children (2 months to 7 years old) who are unable to communicate their pain verbally. It is also useful for children with developmental delays who cannot use self-report pain scales.

The FLACC scale evaluates pain based on five categories, each scored from 0 to 2, for a total possible score of 10:

Face: Expression of discomfort (grimacing, frowning).

Legs: Tension or movement of legs.

Activity: Restlessness or agitation.

Cry: Presence and intensity of crying.

Consolability: Ability to be comforted.

A higher FLACC score indicates greater pain severity, making it a reliable tool for assessing pain in nonverbal children.

Explanation of Incorrect Answers:

Option B: Neonates aged 0 to 6 months. – Incorrect

Neonatal pain is better assessed using the CRIES scale, which specifically evaluates pain in newborns and infants up to 6 months old. The FLACC scale is designed for slightly older infants and children.

Option C: Cognitively impaired adults and elderly patients. – Incorrect

Although some adaptations of FLACC exist for nonverbal adults, the PAINAD (Pain Assessment in Advanced Dementia) scale is more commonly used for older adults with cognitive impairment.

Option D: Postoperative adult patients. – Incorrect

Adults are typically assessed using self-report pain scales, such as the Numeric Rating Scale (NRS), Visual Analog Scale (VAS), or Wong-Baker Faces Pain Scale. The FLACC scale is not meant for verbal adults.

Summary:

The FLACC scale is used to assess pain in nonverbal children aged 2 months to 7 years, including those with developmental disabilities. It evaluates five behavioral indicators of pain and is widely used in pediatric and postoperative care settings where children cannot express pain verbally.

The correct answer is: Custard

Explanation of the Correct Answer:

A full liquid diet includes foods that are liquid or will turn into liquid at body temperature and provide more nutritional value than a clear liquid diet. Custard is a suitable option because it is a smooth, dairy-based food that meets the full liquid diet criteria while also being more satisfying than clear liquids.

Explanation of Incorrect Answers

Tea (Incorrect)

Tea is considered a clear liquid, not a full liquid, because it is transparent and does not contain any solid particles. It was already included in the client’s clear liquid diet, so it does not represent an advancement.

Gelatin (Incorrect)

​​​​​​​Gelatin (e.g., Jell-O) is also a clear liquid, as it becomes a transparent liquid at body temperature. It does not belong in a full liquid diet since it lacks the creamy consistency typical of full liquids.

Popsicle (Incorrect)

​​​​​​​A popsicle is considered part of a clear liquid diet because it melts into a clear liquid, similar to tea and gelatin. It does not provide the additional nutrients or thicker consistency expected in a full liquid diet.

Summary:

​​​​​​​A full liquid diet allows foods with a smooth, creamy consistency that provide more calories and protein than a clear liquid diet. Custard is the best option because it meets these criteria, while tea, gelatin, and popsicles are part of a clear liquid diet and do not signify an advancement.