Nokea
The nurse is assisting the registered nurse with caring for a client who is at 36 weeks gestation. History and Physical Vital Signs
General - Client is gravida 2 para 1 at 36 weeks gestation; reports a throbbing headache rated as / on a scale of 0-10, blurred vision, and epigastric pain; client states that she took 1000 mg of acetaminophen 2 hours ago with no relief, medical history includes seasonal allergies and exercise-induced asthma
Neurological -Patellar deep tendon reflexes 2+ bilaterally, clonus absent
Cardiovascular -Heart tones normal; facial edema noted; +2 pitting edema in bilateral upper extremities; +3 pitting edema in bilateral lower extremities
Gastrointestinal -Client reports fetal movement, no contractions noted; soft uterine resting tone on palpation
Genitourinary -Cervical examination: 1 cm dilated, 0% effaced, -3 fetal station, cephalic fetal presentation, amniotic membranes intact; cesarean birth 5 years ago at 40 weeks gestation for breech fetal presentation, resulting in delivery of healthy newborn
After collecting data on the client, which action should the nurse perform immediately?
- A. Alert the registered nurse
- B. Collect a blood specimen for serum magnesium level
- C. Perform fundal massage
- D. Request a prescription for IV fluids
Correct Answer: A
Rationale: Alerting the registered nurse ensures rapid escalation of care for potential postpartum complications in preeclampsia.
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The nurse is caring for a 69-year-old client.
Progress Notes Emergency Department
1100: The client is unconscious following a suicide attempt. The paramedics immediately initiate CPR.
1115: The nurse reviews the client's chart and is unable to find documentation of a durable power of attorney for health care.
For each rationale, click to specify if the rationale is applicable or not applicable regarding the need to continue cardiopulmonary resuscitation.
- A. The client is unconscious
- B. The client is under the age of 70
- C. The client's toxicology report reveals no illegal substances
- D. The client does not have a living will documented in the medical record
Correct Answer: A,D
Rationale: Unconsciousness and no living will support continuing CPR unless a DNR exists. Age and toxicology are irrelevant.
The nurse is caring for a 12-year-old client.
History and Physical Vital Signs Body System Findings
General- The client has a 2-day history of decreased appetite, nausea, fatigue, and headaches, the client had a "sore throat" 2 weeks ago that resolved without treatment; BMl is in the 65th percentile
Eye, Ears, Nose, and Throat (EENT)- Periorbital edema; no changes in vision
Pulmonary- Lung sounds clear bilaterally; no increased work of breathing; no cough Cardiovascular- S1 and S2 heard on auscultation; no murmur auscultated; 3+ bilateral lower extremity edema is noted
Gastrointestinal- Bowel sounds present, no masses or tenderness felt Musculoskeletal No joint pain or swelling
Genitourinary- Decreased urination; dark, cola-colored urine
Which of the following statements by the parent indicate a correct understanding of the teaching? Select all that apply.
- A. I will contact the health care provider immediately if my child experiences any vision changes, such as blurriness.'
- B. I will schedule a follow-up visit for a urinalysis and blood pressure check.'
- C. My child may notice small amounts of blood in the urine for several weeks.'
- D. My child should avoid exposure to friends and family who show signs of an upper respiratory infection.'
- E. My child will require lifelong blood pressure medication with frequent monitoring at home.'
Correct Answer: A,B,C,D
Rationale: Monitoring vision , follow-up tests , expecting hematuria , and avoiding infections are correct. Lifelong medication is not typical.
The nurse is caring for a 68-year-old client in the emergency department.
History Physical Vital Signs
Admission: The client comes to the emergency department with progressively worsening back pain that began 3 weeks ago. The pain has become significantly worse over the past 12 hours. Pain level is rated as 8 on a scale of 0-10. The client was recently diagnosed with prostate cancer and has had a poor response to treatment. This morning, the client had trouble walking and reports decreased sensation in the feet. The client also reports mild nausea, difficulty urinating, decreased urinary sensation, and no bowel movement in the past 3 days
Which client statement requires immediate follow-up with the health care provider?
- A. Are my feet covered? I cannot feel them anymore.'
- B. I cannot finish my lunch today; my abdomen feels so distended.'
- C. I have been so exhausted since my last chemotherapy treatment.'
- D. When is my next dose of pain medicine? My pain is a 10 out of 10 .'
Correct Answer: A
Rationale: Loss of sensation in the feet suggests worsening spinal cord compression, requiring urgent provider notification.
The newborn nurse is attending births in the labor and delivery unit.
Nurses' Notes
Labor and Delivery Unit
0000: A 39-year-old client, gravida 4 para 3, at 38 weeks gestation arrives at the labor and delivery unit reporting contractions every 2-3 min. During this pregnancy, the client was diagnosed with gestational diabetes mellitus and prescribed insulin, but she reports not taking the insulin. The client reports cigarette smoking (3-5 cigarettes/day) but denies alcohol or recreational drug use. The client received treatment for bacterial vaginosis during the second trimester. The client has gained 55 lb (25 kg) during the pregnancy. Group B Streptococcus result is negative. 1400: The newborn is delivered via forceps-assisted vaginal birth at
1400. The newborn was immediately placed in skin-to-skin contact with the mother, dried, and stimulated. Apgar scores are 7 at 1 minute and 9 at 5 minutes
1405: Newborn vital signs are T 97.3 F (36.3 C), P 156, and RR 52.
1415: Newborn weight is obtained. The newborn is 9 lb 15 oz (4500 g). The maternal client is assisted to latch the newborn onto the breast.
1430: Slight bruising to the scalp is noted where forceps were applied. Newborn vital signs are T 97.2 F (36.2 C), P 160, RR 55, and SpO 95% on room air.
Which of the following interventions should the nurse anticipate when caring for this newborn? Select all that apply.
- A. Administer oral glucose water with each feeding
- B. Allow skin-to-skin contact with the mother when possible
- C. Check the newborn's blood glucose levels
- D. Initiate newborn feeding within the first hour after birth
- E. Monitor the newborn's respiratory rate frequently
- F. Wrap the newborn in warm blankets to alleviate tremors
Correct Answer: B,C,D,E,F
Rationale: Skin-to-skin contact , glucose checks , early feeding , respiratory monitoring , and warming prevent hypoglycemia and respiratory issues.
The nurse is caring for a 40-year-old client.
History Admission:
The client is brought to the psychiatric emergency department by ambulance after being observed walking in the street and shouting at vehicles. The client states that aliens are trying to attack him and that he is now on a mission to find and kill them. The clients mother says that last year he believed that he was being watched by an unidentified government agency and subsequently broke up with his girlfriend, quit his job, and disconnected his phone. The mother has noticed that he no longer seems to care about activities that used to interest him, and last month she discovered that he had moved into the family garden shed with his dog.
On examination, the client is malodorous and disheveled and laughs for no apparent reason. He appears anxious, avoids eye contact, and shows little emotion. His answers are very brief, and he asks if the interview is being secretly recorded. The client's speech is difficult to follow, and he repeatedly says in a monotone voice, "I said I'll find them." He later becomes angry and refuses to sit in a chair for the interview. I'll find them." He later becomes angry and refuses to sit in a chair for the interview.
Which of the following symptoms are consistent with schizophrenia? Select all that apply.
- A. Disorganized speech
- B. Flat affect
- C. Laughing for no apparent reason
- D. Loss of interest in pleasurable activities
- E. Self-care deficit
Correct Answer: A,B,C,D,E
Rationale: Schizophrenia symptoms include disorganized speech , flat affect , inappropriate laughter , anhedonia , and poor self-care .