Nokea
A client who is obese reports severe pain and is unable to bear weight in the right ankle after making dietary changes 3 weeks ago for weight loss. The client's medical history indudes hypertension, gouty arthritis, and cholecystitis. Which instruction should the nurse include in the discharge teaching?
- A. Decrease consumption of red meat and most seafood.
- B. Replace dietary table salt with salt substitutes.
- C. Limit use of mobility equipment to avoid muscle atrophy.
- D. Wrap joints with elastic bandage when swollen.
Correct Answer: A
Rationale: Reducing purine-rich foods like red meat and seafood lowers uric acid levels, helping manage gouty arthritis, which likely causes the ankle pain.
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History and Physical
Nurses' Notes
Orders
Imaging Studies
The client is a young male who appears to be 25 to 30 years old. He was found unconscious on a sidewalk by a jogger who was passing by. The jogger called an ambulance, and the emergency medical technicians (EMTS) transported the client to the hospital. The client is arousable but unable to say what his name is or what happened to him. A STAT head computed tomography (CT) scan in the emergency department showed no abnormalities, so the client will be admitted to the medical floor for observation and further tests.
Exhibits
The nurse comes into the room to replace the IV bag and notices the client's extremities are jerking violently. The client is not arousable and the oxygen saturation is 59% on the monitor.
Based on the information collected, the client is likely experiencing [condition] related to [cause].
- A. Increased intracranial pressure
- B. Brain herniation
- C. Hypoxia
- D. Hypercapnia
- E. Absence seizure
- F. Decorticate posturing
- G. Tonic clonic seizure
Correct Answer: C,F
Rationale: Hypoxia from a tonic-clonic seizure causes low oxygen saturation and jerking movements, requiring urgent intervention.
A client with a large pleural effusion undergoes a thoracentesis. Following the procedure, which observation warrants immediate intervention by the nurse?
- A. The client's chest x-ray Indicates decreased pleural effusion.
- B. The client's arterial blood gas result is a pH 7.35, PaCO, 35 mm Hg, HCO,-26 mEq (26 mmol/L), PaO, 85 mm Hg.
- C. The client has asymmetrical chest wall expansion.
- D. The client reports pain at the insertion site.
Correct Answer: C
Rationale: Asymmetrical chest wall expansion may indicate pneumothorax, a serious complication requiring immediate intervention.
A client is admitted to the emergency department 5 days after an acute coronary syndrome (ACS) troubled by severe fatigue, muscle weakness, and shortness of breath. The client's electrocardiogram (ECG) Indicates sinus tachycardia and the laboratory findings indicate an elevated serum brain natriuretic peptide (BNP) level. Which action is most important for the nurse to implement?
- A. Insert an indwelling urinary catheter.
- B. Obtain blood for serum cardiac enzymes.
- C. Provide emotional support.
- D. Auscultate lung fields for fine rales.
Correct Answer: D
Rationale: Auscultating for rales assesses for pulmonary congestion, indicated by elevated BNP and symptoms, prioritizing over catheter insertion or emotional support.
An older adult client, at risk for osteoporosis, reports taking a multivitamin daily. In developing a teaching plan for the client, which follow- up Information should the nurse obtain?
- A. What time of day the multivitamin is taken.
- B. The amount of calcium in the multivitamin.
- C. Usual activity after taking the multivitamin.
- D. If the multivitamin is taken with a meal or snack
Correct Answer: B
Rationale: Confirming calcium content in the multivitamin ensures adequate intake for bone health, critical for osteoporosis prevention.
The nurse includes the problem of 'Risk for infection' in the plan of care for a client with myelosuppression. Which laboratory value of care provides the greatest support for this nursing problem?
- A. Hematocrit of 33% (0.33 volume fraction).
- B. White blood cell count of 1,500/mm3 (1.5 x 10°)
- C. Hemoglobin of 10 g/dl (6.21 mmol/L)
- D. Red blood cell count of 3.5 x 10l(3.5 x 10°).
Correct Answer: B
Rationale: A low white blood cell count (1,500/mm³) indicates leukopenia, increasing infection risk, unlike other values.