NCLEX-RN Exam Part 10 (676-750)

NCLEX-RN Exam Part 10 

QUESTION 676

The doctor has ordered a restricted fluid intake for a 2- year-old child with a head injury. Normal fluid intake for a child of 2 years is:

A. 900 mL/24 hr

B. 1300 mL/24 hr

C. 1600 mL/24 hr

D. 2000 mL/24 hr

 

QUESTION 677

When discussing the relationship between exercise and insulin requirements, a 26-year-old client with IDDM should be instructed that:

A. When exercise is increased, insulin needs are increased

B. When exercise is increased, insulin needs are decreased

C. When exercise is increased, there is no change in insulin needs

D. When exercise is decreased, insulin needs are decreased

 

QUESTION 678

 

Blood work reveals the following lab values for a client who has been diagnosed with anorexia nervosa: hemoglobin 9.6 g/dL, hemocrit 27%, potassium 2.7 mEq/L, sodium 126 mEq/L. The greatest danger to her at this time is:

A. Hypoglycemia from low-carbohydrate intake

B. Possible cardiac dysrhythmias secondary to hypokalemia

C. Dehydration from vomiting

D. Anoxia secondary to anemia

 

QUESTION 679

 

A 14-year-old boy has a head injury with laceration of his scalp over his ear. The nurse should call the physician to report:

A. Blood pressure increase from 100/80 to 115/85 after lunch

B. Headache that is unresponsive to acetaminophen (Tylenol)

C. Pulse rate ranges between 68 bpm and 76 bpm

D. Temperature rise to 102_F rectally

 

QUESTION 680

 

A 2-year-old boy is in the hospital outpatient department for observation after falling out of his crib and hitting his head. The nurse calls the physician to report:

A. Evidence of perineal irritation

B. Pulse fell from 102 to 96

C. Pulse increased from 96 to 102

D. Temperature rose to 102_F rectally

 

QUESTION 681

 

A client has been in labor 10 hours and is becoming very tired. She has dilated to 7 cm and is at 0 station with the fetus in a right occipitoposterior position. She is complaining of severe backache with each contraction. One comfort measure the nurse can employ is to:

A. Place her in knee-chest position during the contraction

B. Use effleurage during the contraction

C. Apply strong sacral pressure during the contraction

D. Have her push with each contraction

 

QUESTION 682

The nurse is admitting an infant with bacterial meningitis and is prepared to manage the following possible effects of meningitis:

1. Constipation
2. Hypothermia
3. Seizure
4. Sunken fontanelles

 

QUESTION 683

The nurse explains perineal hygiene self-care postpartum to the client. She should be instructed to:

A. Wear gloves for the procedure

B. Place and adjust the pad from back to front

C. Cleanse and wipe the perineum from front to back

D. Protect the outer surface of the pad from contamination

 

QUESTION 684

On morning rounds, the nurse found a manic-depressive client who is taking lithium in a confused mental state, vomiting, twitching, and exhibiting a coarse hand tremor. Which one of the following nursing actions is essential at this time?

A. Administer her next dosage of lithium, and then call the physician.

B. Withhold her lithium, and report her symptoms to the physician.

C. Place her on NPO to decrease the excretion of lithium from her body, and call the physician.

D. Contact the lab and request a lithium level in 30 minutes, and call the physician.

 

QUESTION 685

A registered nurse is trying to determine the appropriate care that she should provide for her obstetrical clients. Which of the following documents is considered the legal standard of practice?

A. State nursing practice act

B. AWHONN Standards for the Nursing Care of Women and Newborns

C. American Nurses’ Association Standards of Maternal- Child Health Nursing

D. International Council of Nurses’ Code

QUESTION 686

A 26-year-old female client presents at 10 weeks’ gestation. She currently is a G3 1-0-1-1. Her mother and grandmother have heart disease. Her grandmother also has insulin-dependent diabetes. The client’s previous delivery was a term female infant weighing 9 lb 13 oz. The client is 5 ft 6 inches tall and her current weight is 130 lb. Based on her history, she is at risk for developing diabetes in pregnancy. Which of the following factors places her at risk for gestational diabetes?

A. Age>25 years

B. Maternal weight

C. Previous birth of an infant weighing>9 lb

D. Family history of heart disease

 

QUESTION 687

A client’s membranes have just ruptured spontaneously. Which of the following nursing actions should take priority?

A. Assess quantity of fluid.

B. Assess color and odor of fluid.

C. Document on fetal monitor strip and chart.

D. Assess fetal heart rate (FHR).

 

QUESTION 688

After several days, an IDDM client’s serum glucose stabilizes, and the registered nurse continues client teaching in preparation for his discharge. The nurse helps him plan an American Diabetes Association diet and explains how foods can be substituted on the exchange list. He can substitute 1 oz of poultry for:

A. One frankfurter

B. One ounce of ham

C. Two slices of bacon

D. One-fourth cup dry cottage cheese

.

QUESTION 689

An IDDM client’s condition stabilizes. He begins to receive a daily injection of NPH insulin at 6:30 AM. The nurse can most likely expect a hypoglycemic reaction to occur that same day at:

 

A. 8:30 AM–10:30 AM

B. 2:30 PM–4:30 PM

C. 7:30 PM–9:30 PM

D. 10:30 PM–11:30 PM

 

QUESTION 690

A husband asks if he can visit with his wife on her ECT treatment days and what to expect after the initial treatment. The nurse’s best response is:

A. “You’ll have to get permission from the physician to visit. Clients are pretty sick after the first treatment.”

 B. “Visitors are not allowed. We will telephone you to inform you of her progress.”

 

C. “There’s really no need to stay with her. She’s going to sleep for several hours after the treatment.”

D. “Yes, you may visit. She may experience temporary drowsiness, confusion, or memory loss after each treatment.”

 

QUESTION 691

A female client admitted to the labor and delivery unit thinks her bag of water “broke” approximately 2 hours ago. She is having mild contractions 5 minutes apart. The most immediate nursing intervention would be to:

A. Note the color and amount of fluid on her clothes.

B. Assess the FHR.

C. Notify the physician.

D. Place the nitrazine test paper at the cervical os and note the color change.

 

QUESTION 692

Medication is administered to a client who has been placed in restraints after a sudden violent episode, and his

EPSs subside. Restraints can be removed when:

A. The physician orders it

B. A therapeutic alliance has been established, and violent behavior subsides

C. The violent behavior subsides, and the client agrees to behave

D. The nurse deems that removal of restraints is necessary

 

QUESTION 693

The nurse assesses a client’s monitor strip and finds the following: uterine contractions every 3–4 minutes, lasting 60–70 seconds; FHR baseline 134–146 bpm, with accelerations to 158 bpm with fetal movement. Which nursing intervention is appropriate?

A. Notify physician of nonreassuring FHR pattern.

B. Turn the client to her left side.

C. Start IV for fetal distress and administer O2 at 6–8 liters by mask.

D. Evaluate to see if the monitor strip is reassuring.

 

QUESTION 694

A 14-year-old boy fell off his bike while “popping a wheelie” on the dirt trails. He has sustained a head injury with laceration of his scalp over his temporal lobe. If he were to complain of headache during the first 24 hours of his hospitalization, the nurse would:

A. Ask the physician to order a sedative

B. Have the client describe his headache every 15 minutes

C. Increase his fluid intake to 3000 mL/24 hr

D. Offer diversionary activities

 

 

QUESTION 695

 

A client at 6 months’ gestation complains of tiredness and dizziness. Her hemoglobin level is 10 g/dL, and her hematocrit value is 32%. Her nutritional intake is assessed as sufficient. The most likely diagnosis is:

A. Iron-deficiency anemia

B. Physiological anemia

C. Fatigue due to stress

D. No problem indicated

 

 

QUESTION 696

A baby is circumcised. Immediate postoperative care should include:

A. Applying a loose diaper

B. Keeping the baby NPO for 4 hours to avoid vomiting

C. Changing the dressing frequently using dry, sterile gauze

D. Taking the baby to his mother for cuddling

 

QUESTION 697

A client who has been diagnosed with anorexia nervosa reluctantly agrees to eat all prescribed meals. The most important intervention in monitoring her dietary compliance would be to:

A. Allow her privacy at mealtimes

B. Praise her for eating everything

C. Observe behavior for 1–2 hours after meals to prevent vomiting

D. Encourage her to eat in moderation, choose foods that she likes, and avoid foods that she dislikes

 

QUESTION 698

The nurse has been caring for a 16-year-old female who recently experienced date rape. After having had crisis intervention and been hospitalized for 2 weeks, the nurse knows

that the client is effectively coping with the rape when she tells the nurse:

A. “I know it was my fault that it happened, because I shouldn’t have been out so late.” B. “If I had not worn that sexy dress that night, he wouldn’t have raped me.”

C. “I know my date just had so much passion he couldn’t handle me saying ‘no.’ ”

D. “I know now that it was not my fault, but I want to continue counseling after my discharge.”

 

QUESTION 699

A 24-year-old woman who is gravida 1 reports, “I can’t take iron pills because they make me sick.” She continues, “My bowels aren’t moving either.” In counseling her based on these complaints, the nurse’s most appropriate response would be, “It would be beneficial for you to eat . . .

1. prunes.”
2. green leafy vegetables.”
3. red meat.”
4. eggs.”

 

 

QUESTION 700

The physician of an alcoholic client places him on a low-protein, high-carbohydrate diet. When choosing his menu, the client’s best choice from the items below would be:

A. Liver and onions, macaroni and cheese, tea with sugar

B. Baked chicken, baked potato with bacon bits, milk

C. Waffles with butter and honey, orange juice

D. Cheese omelette with ham and mushrooms, milk

 

QUESTION 701

In evaluating the effectiveness of magnesium sulfate (MgSO4), which of the following might indicate that the client was developing MgSO4 toxicity?

A. A 31 patellar tendon reflex

B. Respirations of 12 breaths/min

C. Urine output of 40 mL/hr

D. A 21 proteinuria value

 

QUESTION 702

Assessment of a client reveals a 30% loss of preillness weight, lanugo, and cessation of menses for 3 months. Her vital signs are BP 90/50, P 96 bpm, respirations 30, and temperature 97 F. She admits to the nurse that she has induced vomiting 3 times this morning, but she had to continue exercising to lose “just 5 more lb.” Her symptoms are consistent with:

1. Pregnancy
2. Bulimia
3. Gastritis
4. Anorexia nervosa

 

QUESTION 703

A 16-year-old female client is admitted to the hospital because she collapsed at home while exercising with videotaped workout instructions. Her mother reports that she has been obsessed with losing weight and staying slim since cheerleader try-outs 6 months ago, when she lost out to two of her best friends. The client is 5’4” and weighs 92 lb, which represents a weight loss of 28 lb over the last 4 months. The most important initial intervention on admission is to:

A. Obtain an accurate weight

B. Search the client’s purse for pills

C. Assess vital signs

D. Assign her to a room with someone her own age

 

QUESTION 704

A new mother experiences strong uterine contractions while breast-feeding her baby. She excitedly rings for the nurse. When the nurse arrives the mother tells her, “Something is wrong. This is like my labor.” Which reply by the nurse identifies the physiological response of the client?

A. “Your breasts are secreting a hormone that enters your bloodstream and causes your abdominal muscles to contract.”

 

B. “Prolactin increases the blood supply to your uterus, and you are feeling the effects of this blood vessel engorgement.”

 

C. “The same hormone that is released in response to the baby’s sucking, causing milk to flow, also causes the uterus to contract.”

 

D. “There is probably a small blood clot or placental fragment in your uterus, and your uterus is contracting to expel it.”

 

 

QUESTION 705

A client presented herself to the mental health center, describing the following symptoms: a weight loss of 20 lb in the past 2 months, difficulty concentrating, repeated absences from work due to “fatigue,” and not wanting to get dressed in the morning. She leaves her recorded message on her telephone and has lost interest in answering the phone or doorbell. The nurse’s assessment of her behavior would most likely be:

A. Deep depression

B. Psychotic depression

C. Severe anxiety

D. Severe depression

 

QUESTION 706

A client’s record from the ED indicates that she overdosed on phenelzine sulfate (Nardil), a monoamine oxidase (MAO) inhibitor. Which diet would be the most appropriate at this time?

A. High carbohydrate, low cholesterol

B. High protein, high carbohydrate

C. 1 g sodium

D. Tyramine-free

 

QUESTION 707

Which of the following symptoms might the nurse observe in a client with a lithium blood level over 2.0?

A. Fine hand tremor, headache, mental dullness

B. Vomiting, impaired consciousness, decreased blood pressure

C. Polyuria, polydipsia, edema

D. Gastric irritation, nausea, diarrhea

 

QUESTION 708

A client with IDDM is given IV insulin for a blood glucose level of 520 mg/dL. Life-threatening complications may occur initially, so the nurse will monitor him closely for serum:

A. Chloride level of 99 mEq/L

B. Sodium level of 136 mEq/L

C. Potassium level of 3.1 mEq/L

D. Potassium level of 6.3 mEq/L

 

QUESTION 709

The nurse and prenatal client discuss the effects of cigarette smoking on pregnancy. It would be correct for the nurse to explain that with cigarette smoking there is increased risk that the baby will have:

A. A low birth weight

B. A birth defect

1. Anemia
2. Nicotine withdrawal

 

QUESTION 710

A 26-year-old male client is brought by his wife to the emergency department (ED) unconscious. Blood is drawn for a stat blood count (CBC), fasting blood sugar level, and electrolytes. An indwelling urinary catheter is inserted. He has a history of type 1 diabetes (insulindependent diabetes mellitus [IDDM]). A diagnosis of ketoacidosis is made. Stat lab values reveal a blood sugar level of 520 mg/dL. Which of the following should

the nurse expect to administer in the ER?

A. D50W by IV push

B. NPH insulin SC

C. Regular insulin by IV infusion

D. Sweetened grape juice by mouth

QUESTION 711

In teaching the client about proper umbilical cord care, the nurse recommends that:

A. Petrolatum be placed around the cord after the sponge bath

B. A belly binder be applied to prevent umbilical hernia

C. The area be cleansed at diaper changes with alcohol and inspected for redness or drainage

 D. The cord clamp be left on until the cord stump separates

.

QUESTION 712

A 24-hours’ postpartum client complains of discomfort at the episiotomy site. On assessment, the nurse notes the episiotomy is without signs of infection. To relieve the discomfort, the nurse should first:

A. Assist her with a sitz bath

B. Administer the prescribed medication for pain

C. Teach her Kegel exercises

D. Apply an ice pack

 

QUESTION 713

Due to his prolonged history of alcohol abuse, an alcoholic client will most likely have deficiencies of which of the following nutrients?

A. Vitamin C and zinc

B. Folic acid and niacin

C. Vitamin A and biotin

D. Thiamine and pyroxidine

 

QUESTION 714

A female client has been treated since childhood for mitral valve prolapse. The antibiotic of choice for her during pregnancy would be:

1. Sulfa
2. Tetracycline
3. Hydralazine
4. Erythromycin

 

QUESTION 715

A client is being admitted to the labor and delivery unit. She has had previous admissions for “false labor.” Which clinical manifestation would be most indicative of true labor?

A. Increased bloody show

B. Progressive dilatation and effacement of the cervix

C. Uterine contractions

D. Decreased discomfort with ambulation

 

QUESTION 716

A 2-year-old boy fell out of bed and has a subdural hematom

A. When his mother leaves him for the first time, you will expect the child to:

A. Be comforted when he is held

1. Cry
2. Not notice that his mother has left
3. Withdraw and become listless

 

QUESTION 717

A client undergoes a transurethral resection, prostate (TURP). He returns from surgery with a three-way continuous Foley irrigation of normal saline in progress. The purpose of this bladder irrigation is to prevent:

A. Bladder spasms

B. Clot formation

C. Scrotal edema

D. Prostatic infection

 

QUESTION 718

A 2-year-old child is recovering from surgery. Considering growth and development according to Erikson, the nurse identifies which of the following play activities as most appropriate?

A. Assembling a puzzle with large pieces

B. Being taken for a wheelchair ride

C. Listening to a story about the Muppets

D. Watching Sesame Street on television

 

QUESTION 719

A 30-year-old client in the third trimester of her pregnancy asks the nurse for advice about upper respiratory discomforts. She complains of nasal stuffiness and epistaxis, most noticeable on the left side. Which reply by the nurse is correct?

A. “It sounds as though you are coming down with a bad cold. I’ll ask the doctor to prescribe a decongestant for relief of symptoms.”

B. “A good vaporizer will help; avoid the cool air kind. Also, try saline nose drops, and spend less time on your left side.”

C. “These discomforts are all a result of increased blood supply; one of the pregnancy hormones, estrogen, causes them.”

D. “This is most unusual. I’m sure your obstetrician will want you to see an ENT (ear, nose, throat) specialist.”

 

QUESTION 720

The nurse is caring for a 6-week-old girl with meningitis. To help her develop a sense of trust, the nurse should:

A. Give her a small soft blanket to hold

B. Give her good perineal care after each diaper change

C. Leave the door open to her room

D. Pick her up when she cries

 

QUESTION 721

Early in her ninth month of pregnancy, a client has been diagnosed as having mild preeclampsi

A. In counseling her about her diet, the nurse must emphasize the importance of:

E. Decreasing her sodium intake

F. Decreasing her fluids

G. Increasing her carbohydrate intake

H. Eating a moderate to high-protein diet

 

QUESTION 722

A client is having an amniocentesis. Prior to the procedure, an ultrasound is performed. In preparing the client, the nurse explains the reason for a sonogram in this situation to be:

A. Determination of multiple gestations

B. Determination of gross anomalies

C. Determination of placental location

D. Determination of fetal age

 

QUESTION 723

The nurse is caring for a 3-month-old girl with meningitis. She has a positive Kernig’s sign. The nurse expects her to react to discomfort if she:

A. Dorsiflexes her ankle

B. Flexes her spine

C. Plantiflexes her wrist

D. Turns her head to the side

 

QUESTION 724

On the third postpartum day, a client complains of extremely tender breasts. On palpation, the nurse notes a very firm, shiny appearance to the breasts and some milk leakage. She is bottle feeding. The nurse should initially recommend to her to:

A. Take 2 ibuprofen (Motrin) tablets by mouth now because the baby will be returning for feeding in 20 minutes

B. Allow the infant to breast-feed at the next feeding time to empty the breasts

C. Apply ice packs to the breasts and wear a supportive, well-fitting bra

D. Take a warm shower and express milk from both breasts until empty

 

QUESTION 725

A psychiatric nurse is providing an orientation to a new staff nurse. She reminds the nurse that psychiatrists often use categories of medications and that it is important that she recall that some categories of medications have synonyms. Another name used to describe minor tranquilizers is which of the following?

A. Antipsychotic medications

B. Antidepressant medications

C. Antianxiety medications

D. Antimania medication

 

QUESTION 726

A client is medically cleared for ECT and is tentatively scheduled for six treatments over a 2-week period. Her husband asks, “Isn’t that a lot?” The nurse’s best response is:

A. “Yes, that does seem like a lot.”

B. “You’ll have to talk to the doctor about that. The physician knows what’s best for the client.”

C. “Six to 10 treatments are common. Are you concerned about permanent effects?” D. “Don’t worry. Some clients have lots more than that.”

 

QUESTION 727

A client is pleased about being pregnant, yet states, “It is really not the best time, but I guess it will be OK.” The nurse’s assessment of this response is:

1. Initial maternal-infant bonding may be poor.
2. Client may have a poor relationship with her husband.
3. This response is normal in the first trimester.
4. This response is abnormal, to be re-evaluated at the next visit.

 

QUESTION 728

A client suffering from schizophrenia has been taking chlorpromazine (Thorazine) for 6 months. On one of his follow-up visits to the mental health center, the nurse reports to the physician that he has developed tardive dyskinesi

 

A. Which of the following symptoms might she have observed in the client to support this conclusion?

A. High fever, tachycardia, stupor, renal failure

B. Lip smacking, chewing, blinking, lateral jaw movements

C. Photosensitivity, orthostatic hypotension, dry mouth

D. Constipation, blurred vision, drowsiness

 

QUESTION 729

A pregnant client complains of varicosities in the third trimester. Which of the following activities should she be advised to avoid?

E. Sitting with legs crossed at ankles

F. Wearing thromboembolic disease (TED) stockings

G. Wearing support pantyhose

H. Wearing knee-high stockings

 

QUESTION 730

The nurse is trying to help a mother understand what is happening with her son who has recently been diagnosed with paranoid schizophreni

A. At present, he is experiencing hallucinations and delusions of persecution and suffers from poor hygiene. The nurse can best help her understand her son’s condition by which of the following statements?

A. “Sometimes these symptoms are caused by an overstimulation of a chemical called dopamine in the brain.” B. “Has anyone in your family ever had schizophrenia?”

C. “If your son has a twin, he probably will eventually develop schizophrenia, too.”

D. “Some of his symptoms may be a result of his lack of a strong mother-child bonding relationship.”

 

QUESTION 731

A couple is experiencing difficulties conceiving a baby. The nurse explains basal body temperature (BBT) by instructing the female client to take her temperature:

A. Orally in the morning and at bedtime

B. Only one time during the day as long as it is always at the same time of day

C. Rectally at bedtime

D. As soon as she awakens, prior to any activity

 

QUESTION 732

 

A 23-year-old male client is admitted to the chemical dependency unit with a medical diagnosis of alcoholism. He reports that the last time he drank was 3 days ago, and that now he is starting to “feel kind of shaky.” Based on the information given above, nursing care goals for this client will initially focus on:

A. Self-concept problems

B. Interpersonal issues

C. Ineffective coping skills

D. Physiological stabilization

 

QUESTION 733

Often children are monitored with pulse oximeter. The pulse oximeter measures the:

A. O2 content of the blood

B. Oxygen saturation of arterial blood

1. PO2
2. Affinity of hemoglobin for O2

 

QUESTION 734

 

The nurse writes the following nursing diagnosis for a client in acute renal failure—Impaired gas exchange related to:

A. Decreased red blood cell production

B. Increased levels of vitamin D

C. Increased red blood cell production

D. Decreased production of renin

 

QUESTION 735

In caring at home for a child who just ingested a caustic alkali, the nurse would immediately tell the mother to:

A. Give vinegar, lemon juice, or orange juice

B. Phone the doctor

C. Take the child to the emergency room

D. Induce vomiting

 

QUESTION 736

A client hospitalized with a medical diagnosis of adjustment disorder versus personality disorder states, “Nobody cares about the clients.” The nurse’s most effective response would be:

A. “How can you say that I don’t care? We just met.”

B. “What makes you think the nurses don’t care?”

C. “You will feel differently about us in a few days.”

D. “You seem angry. Tell me more about how you feel.”

 

QUESTION 737

A 6-month-old infant who was diagnosed at 4 weeks of age with a ventricular septal defect, was admitted today with a diagnosis of failure to thrive. His mother stated that he had not been eating well for the past month. A cardiac catheterization reveals congestive heart failure. All of the following nursing diagnoses are appropriate. Which nursing diagnosis should have priority?

A. Altered nutrition: less than body requirements related to inability to take in adequate calories

B. Altered growth and development related to decreased intake of food

C. Activity intolerance related to imbalance between oxygen supply and demand

D. Decreased cardiac output related to ineffective pumping action of the heart

 

QUESTION 738

One of the most reliable assessment tools for adequacy of fluid resuscitation in burned children is:

A. Blood pressure

B. Level of consciousness

C. Skin turgor

D. Fluid intake

 

QUESTION 739

A 35-year-old client is receiving psychopharmacological treatment of his major depression with tranylcypromine sulfate (Parnate), a monoamine oxidase (MAO) inhibitor. The nurse teaches the client that while he is taking this type of antidepressant, he needs to restrict his dietary intake of:

1. Potassium-rich foods
2. Tryptophan
3. Tyramine
4. Saturated fats

 

QUESTION 740

A 19-month-old child is admitted to the hospital for surgical repair of patent ductus arteriosus. The child is being given digoxin. Prior to administering the medication, the nurse should:

A. Not give the digoxin if the pulse is_60

B. Not give the digoxin if the pulse is_100

C. Take the apical pulse for a full minute

D. Monitor for visual disturbances, a side effect of digoxin

 

QUESTION 741

Two hours after the second injection of haloperidol, a client complains to the nurse of a stiff neck and inability to sit still. He is experiencing symptoms consistent with:

A. Parkinsonism and dystonia

B. Dystonia and akathisia

C. Akathisia and parkinsonism

D. Neuroleptic malignant syndrome

 

QUESTION 742

Three hours postoperatively, a 27-year-old client complains of right leg pain after knee reduction. The first action by the nurse will be to:

A. Assess vital signs

B. Elevate the extremity

C. Perform a lower extremity neurovascular check

D. Remind the client that he has a client-controlled analgesic pump, and reinstruct him on its use

 

QUESTION 743

A 4-year-old boy is brought to the emergency room with bruises on his head, face, arms, and legs. His mother states that he fell down some steps. The nurse suspects that he may have been