Test Board

Nurses’ Notes at 0700hrs
The client appears fatigued and reports a persistent headache. He has been experiencing muscle aches throughout his body. He also complains of a sore throat and has had a fever for the past two days. The client’s skin is warm to the touch and he appears slightly dehydrated.
Vital Signs at 0700hrs
• Temperature: 39.5°C (103.1°F)
• Blood pressure: 128/56 mm Hg
• Heart rate: 112/min
• Respiratory rate: 22/min
• SaO2: 96% on room air
Diagnostic Results at 0700hrs
• Complete blood count shows elevated white blood cells
• Throat culture has been sent to the lab for analysis
• Chest X-ray pending

Nurse's Notes & Physical Examination
• The client arrived in the emergency department with complaints of fatigue, blurred vision, dizziness, and headache for the past two days. They report running out of blood glucose strips and insulin due to financial constraints. The client appears tired, is cooperative, and has a slightly dry mucous membrane. They are oriented to person, place, and time but seem concerned about their health status. The skin is warm and dry to the touch, with no visible rashes or lesions. Heart sounds are regular without murmurs; breath sounds are clear bilaterally. The abdomen is soft with no tenderness upon palpation. The client expresses anxiety about potential falls due to dizziness.
Vital Signs
• Blood Pressure: 120/72 mm Hg
• Temperature: 36.8° C (98.2° F)
• Pulse: 88/min
• Respirations: 20/min
Diagnostic Results
• Blood Glucose: 235 mg/dL (Reference range: 74-106 mg/dL)
• HbA1c: 8.4% (Target for diabetics: <7%)
• Hemoglobin: 14.2 g/dL (12-18 g/dL)
• Hematocrit: 42.6% (37-52%)
• WBC Count: 6000/mm³ (5000-10,000/mm³)
Provider's Prescriptions
• Increase glargine from 20 units to 25 units at bedtime.
• Continue other home medications as prescribed.
Scenario: A nurse is caring for a client admitted to the medical-surgical unit. The exhibits below detail the client's condition at different time points throughout the day. Review the exhibits and determine how the patient's condition evolves and whether it worsens or improves. The initial data is recorded at 0700 hrs, followed by subsequent observations at different times.

Nurse's Notes & Physical Examination
• The client is found attempting to climb out of bed, stating, "People are trying to hurt me." They are highly agitated and disoriented, attempting to remove IV lines. The client's behavior is erratic, and they require constant supervision. The skin is now cool and pale, with poor capillary refill. Respirations are labored, and the client is using accessory muscles to breathe. Lung sounds have deteriorated, with coarse crackles heard throughout. The abdomen is firm, and the client expresses significant discomfort. The urinary catheter output has decreased, and urine appears concentrated.
Vital Signs
• Blood Pressure: 100/64 mm Hg
• Temperature: 37.3° C (99.1° F)
• Pulse: 110/min
• Respirations: 28/min
Diagnostic Results
• Hemoglobin: 12.5 g/dL
• Hematocrit: 38.0%
• AST: 52 units/L
• ALT: 49 units/L
Provider's Prescriptions
• Soft wrist restraints if necessary.
• Immediate reassessment and adjustment of care plan.
2100 hrs - Critical Incident

Nurse's Notes & Physical Examination
• The client has been lying in bed and appears more fatigued than earlier. They complain of increased dizziness and a persistent headache. The nausea has worsened, and the client reports feeling faint upon sitting up. There is noticeable pallor, and the skin feels cool to touch. The client is breathing rapidly and appears anxious, stating that they feel something is not right. Heart rate has increased further, and rhythm remains regular but fast. Lung sounds are now clear bilaterally without diminished areas. The client still requires assistance for ambulation due to unsteadiness.
Vital Signs
• Blood Pressure: 110/68 mm Hg
• Temperature: 36.4° C (97.5° F)
• Pulse: 98/min
• Respirations: 24/min
Diagnostic Results
• Hemoglobin: 13.4 g/dL
• Hematocrit: 40.8%
• Blood Glucose: 245 mg/dL
• Serum Potassium: 4.8 mEq/L (Reference range: 3.5-5.0 mEq/L)
Provider's Prescriptions
• Administer IV fluids at 75 mL/hr.
• Recheck blood glucose level in 2 hours.
• Continue monitoring fluid intake and output.

Scenario :A nurse is caring for a client admitted to the medical-surgical unit. The exhibits below detail the client's condition at different time points throughout the day. Review the exhibits and determine how the client's condition evolves and whether it worsens or improves.
1500 hrs - Follow-Up Assessment

History & Physical (0700hrs)
Date: 06/28/0X
• Client presented to the clinic reporting pelvic pain, dysmenorrhea, dyspareunia, and pain with defecation.
• Vaginal examination reveals fixed, palpable nodules with a retroverted uterus.
• Imaging reveals endometrial lesions on the ovaries, uterosacral ligaments, and round ligaments.
• Endometriosis diagnosed.
Provider's Prescriptions (0700hrs)
• Nafarelin 200 mcg: 1 spray intranasally every morning and 1 spray in the opposite nostril every evening.
Nurse's Notes (0700hrs)
• Client reports adherence to nafarelin regimen without missing doses.
• Client verbalizes irritation in the nasal mucosa.
• Reports feeling better overall with decreased dyspareunia.
• Notes decreased pain during bowel movements.
• Reports decreased pelvic pain and the absence of menstruation last month.
• Mentions experiencing headaches, increased acne, and reduced sex drive since starting treatment.
• Client observes a decrease in breast size.
Scenario:
A nurse is caring for a 32-year-old female client who was recently diagnosed with endometriosis. The client is in the clinic for a follow-up visit after beginning nafarelin treatment.
Setting: Clinic