NCLEX-PN case studies, step by step

Question 1

After the UAP reports being struck, the nurse reviews the client's record at 0700 on Day 3. Click to highlight the findings that the nurse should report to the registered nurse (RN).

Accepted Answer

At 0600 the UAP woke the client for a complete bed bath before morning tests; Struck the UAP on the arm when the UAP began washing the client's chest; Awake from 0100 to 0430 calling out and trying to climb over the side rails; Slept in the chair from 1300 to 1600 yesterday; Diphenhydramine 25 mg orally at bedtime as needed for sleep, given at 2200 on Day 2. A client with moderate dementia cannot always say what is wrong, so behavior becomes the message. Striking out during a bath is a sign of fear, not a personality change. This client has never struck anyone before, so something about the situation triggered it.

The highlighted findings explain the behavior and point to risk. The client was woken at 0600 for a bed bath, a time and a type of bath unlike the evening tub bath at home. The client was awake from 0100 to 0430 and tried to climb over the side rails, which is a serious fall risk. A 3-hour afternoon nap shifts sleep away from the night. Diphenhydramine is strongly anticholinergic, and in older adults it worsens confusion and agitation, so it may have added to the night's restlessness rather than relieving it.

Question 2

The nurse compares the findings recorded at 0700 on Day 3 with the daughter's description of the client's routine at home. For each finding below, click to specify whether the finding is a likely contributor to the client's resistance to bathing, night wakefulness, or both.

Accepted Answer

A 3-hour nap in the chair the afternoon before: Night wakefulness; Vital signs and repositioning at 0000, 0200, and 0400: Night wakefulness; Woken at 0600 for a complete bed bath: Resistance to bathing; Diphenhydramine at 2200: Resistance to bathing, Night wakefulness; A bed bath in place of the usual evening tub bath: Resistance to bathing; Coffee at 1500: Night wakefulness. A client with dementia depends on routine, because a familiar sequence is easier to follow than a new one. A bath is an intimate and often cold, exposed experience, and when it comes at an unfamiliar hour, in an unfamiliar way, from someone the client may not recognize, it feels like an attack. Waking the client at 0600 for a bed bath broke both the time and the type of the client's usual bath.

Night wakefulness has several causes here. A long afternoon nap uses up the client's need for sleep. Caffeine at 1500 is still active at midnight. Waking the client at 0000, 0200, and 0400 breaks sleep into short pieces. Diphenhydramine fits both columns. Its anticholinergic effects cause confusion and agitation in older adults, which can worsen night restlessness and leave the client more confused and frightened when woken in the morning.

Question 3

At 0700 on Day 3, the nurse prepares to report to the registered nurse (RN). Which of the following client problems is the priority to report?

Accepted Answer

D: Risk of a fall from climbing over the side rails at night. The client tried to climb over the side rails during the night. A client with dementia who is confused, awake, and determined to get up can fall from the full height of the rails, which is higher than falling from a low bed. A fall in an 81-year-old can cause a hip fracture or a head injury, which can be life-threatening. Preventing injury comes first.

The other problems are real and are addressed in the same plan, but none puts the client in immediate physical danger.

Question 4

Before the 1000 care conference on Day 3, the nurse prepares suggestions to contribute to the plan of care. For each potential intervention, click to specify if the intervention is indicated or not indicated for the care of the client.

Accepted Answer

Ask the provider about stopping the bedtime diphenhydramine: Indicated; Raise all four side rails at night to keep the client in bed: Not indicated; Offer the bath in the evening, at the time the client bathed at home: Indicated; Ask a second staff member to hold the client's arms so the morning bath can be finished: Not indicated; Use a towel bath in a warm room and uncover one body area at a time: Indicated; Request a prescription for haloperidol to give before each bath: Not indicated. The plan removes the triggers rather than forcing the task. Moving the bath to the evening, when the client bathed at home, gives the client a familiar routine. A towel bath, in which the client is washed under a warm, damp towel with one area uncovered at a time, keeps the client warm and covered. Hymns, the same caregiver, and simple one-step directions in a calm voice add to the client's sense of safety. Stopping diphenhydramine removes a medication that worsens confusion in older adults.

Question 5

The nurse reviews the Day 3, 1000 prescriptions. Which of the following actions should the nurse take over the next 24 hours?

Accepted Answer

A: Keep the room dark after 2200 except for a dim night light; B: Offer decaffeinated coffee with lunch and in the afternoon; C: Assist the client to the toilet at bedtime and at 0200; E: Wake the client after a 30-minute afternoon nap in the chair. These actions put the plan into practice. A short nap, with the prescribed walks in the hallway, builds the client's need for sleep at night, and daytime light and activity help reset the sleep-wake rhythm. Decaffeinated drinks after noon keep caffeine from delaying sleep. Toileting at bedtime and at 0200 meets the most common reason older adults get up at night, and a low bed with a floor mat limits injury if the client gets up anyway. Darkness at the client's usual bedtime supports the sleep-wake rhythm, while a dim night light lets the client find the way and lets staff observe during hourly rounding without keeping the client awake.

Question 6

The daughter arrives at 0700 on Day 5 and asks whether the new approach is working. For each finding in the Day 5, 0700 record, click to specify if the finding indicates that the client's condition has improved, has not changed, or has declined since Day 3.

Accepted Answer

Found sitting on the floor mat beside the bed at 0545: Declined; Slept from 2200 to 0500, waking once to use the toilet: Improved; Napped 30 minutes on Day 4: Improved; Oriented to person only: Not changed; Calm during the evening towel bath and washed own face and hands: Improved. The changes to the bath worked. The client stayed calm and helped by washing the face and hands, which also supports the client's remaining abilities. Night sleep now matches the client's home pattern, with one awakening that was met by scheduled toileting, and the nap has been kept short. Orientation to person only is the client's baseline with moderate Alzheimer disease and is not expected to change.

The client was found on the floor mat at 0545. The low bed and mat may have prevented an injury, but the client still got out of bed without help, which is a fall. The nurse checks the client for injury, reports the fall to the registered nurse (RN) and the provider, documents it, and looks for the reason, such as needing the toilet again after waking at 0500, so the fall precautions can be updated.

Question 7

The nurse finds the resident on the bathroom floor at 0630 and checks the resident before any move. Click to highlight the findings that the nurse should report to the registered nurse (RN).

Accepted Answer

Right wrist swollen with pain rated 6 out of 10; 2 cm skin tear on the right forearm with slight oozing. Every fall is reported to the RN, and the findings that describe an injury are the ones the RN and the provider need first.

A swollen, painful wrist after landing on an outstretched hand is the classic way older adults break the end of the radius. This resident has osteoporosis, which makes the bone thin and easy to break. A skin tear is a wound where the thin outer layer of older skin peels away from the layer below. It is a minor injury, but it is still an injury from the fall and needs care and documentation.

Question 8

The resident is sitting on the bathroom floor at 0630. The nurse inspects the bathroom. For each finding below, click to specify if the finding indicates a contributing factor or an injury.

Accepted Answer

Right wrist swollen and painful: Injury; Floor wet near the sink: Contributing factor; 2 cm skin tear on the right forearm: Injury; Socks without grips: Contributing factor; Walker out of reach beside the bed: Contributing factor. A fall in a long-term care resident usually comes from the resident and the room together. Parkinson disease causes a shuffling gait and poor balance, so the feet do not clear the floor well. A wet floor and socks without grips take away the little traction the resident has. Leaving the walker by the bed meant the resident walked without support.

The wrist swelling and the skin tear are what the fall caused. Telling the two groups apart matters, because the injuries are treated and the factors are fixed so the fall does not happen again.

Question 9

The nurse has finished checking the resident on the bathroom floor at 0630 and is ready to call the RN. Which of the following client problems is the priority to report?

Accepted Answer

D: A possible fracture of the right wrist. A fracture is a break in the bone. In an older adult with osteoporosis, a fall onto an outstretched hand often breaks the distal radius, just above the wrist. Swelling, pain and sometimes a visible bend are the signs. A fracture needs an X-ray, immobilization and a check of the circulation in the fingers, because swelling can press on vessels and nerves.

It is the priority problem because it is the most serious injury and needs provider orders. The other problems are real, and the nurse handles them, but none of them can cause lasting harm the way a missed fracture can.

Question 10

The nurse is waiting for the RN to arrive after the 0630 fall. Which of the following interventions would the nurse expect to be included in the plan of care?

Accepted Answer

B: Keep the right wrist still and supported on a pillow until it is examined; D: Rinse the skin tear with 0.9% sodium chloride and cover it with a nonadherent dressing; E: Place nonskid socks on the resident and keep the walker within reach. The plan treats the injuries and prevents the next fall. A possible fracture is kept still and supported, because movement adds pain and can shift the broken bone. Elevation and ice reduce swelling once ordered.

A skin tear is rinsed gently, and if the flap of skin is still attached it is laid back into place and covered with a nonadherent dressing. Adhesive tape is kept off fragile skin. Nonskid socks and a walker within reach remove two of the factors that caused this fall.

Question 11

The resident is still sitting on the bathroom floor at 0630. Place the following actions in the order the nurse should perform them.

Accepted Answer

1: Check the resident for injury before any move; 2: Call for help and move the resident to a chair with 2 staff members and a gait belt; 3: Report the fall and the findings to the RN; 4: Document the objective findings and care in the medical record; 5: Complete an incident report. The order follows the resident first and the paperwork last. The check comes before any move, because moving a resident with a broken bone or a head injury can make the injury worse. The nurse then calls for help and moves the resident with enough staff and a gait belt, supporting the injured wrist, and never lifts alone. The RN is told next, so the RN can see the resident and the provider can give orders.

The medical record entry follows. It lists what the nurse saw and did: the time, where the resident was found, the resident's own words in quotation marks, the findings, who was told and the care given. The incident report comes last. It is a separate form for the facility's quality and safety review and is never mentioned in or filed with the medical record.

Question 12

The nurse checks the resident at 1200 after the splint was applied. For each finding, click to specify whether the finding indicates that the client's condition has improved or requires follow-up.

Accepted Answer

Resident plans to get up alone at night: Requires follow-up; Right fingers warm and pink with capillary refill under 2 seconds: Improved; Wrist pain rated 2 out of 10 after acetaminophen: Improved; Incident report clipped inside the medical record: Requires follow-up; Nonskid socks on and walker within reach: Improved. The care plan is working. Warm, pink fingers with a quick capillary refill show that the splint and the swelling are not cutting off circulation. The pain has dropped from 6 to 2 out of 10, and the fall precautions are in place.

The resident's plan to get up alone at night needs follow-up. It shows the resident does not want to bother the staff, which is common in older adults and is a strong risk for another fall. The nurse reinforces why to use the call light, places it within reach, keeps the toileting schedule and reports the statement to the RN so the plan can include it.

The incident report in the medical record needs follow-up too. The incident report is a confidential quality document. It does not belong in the medical record, and the record does not mention it. The nurse removes the copy and returns it to the person who handles incident reports per facility policy.

NCLEX-PN case studies, step by step.

Case study 1