Nokea
The nurse in the emergency department is caring for a 62-year-old client.
History and Physical
Neurological
The client is alert and oriented to time, place, person, and situation; the client reports sudden-onset right-sided facial drooping, speech is slurred; positive right-sided arm drift is seen
Eye, Ear, Nose, and Throat (EENT)
Bilateral pupils are equal, round, and reactive to light and accommodation
Pulmonary
Vital signs: RR 16, SpO, 95% on room air, lung sounds are clear bilaterally
Cardiovascular
Vital signs: T 99 F (37.2 C), P 86, BP 166/90; S1 and S2 are heard on auscultation; no murmurs are noted; the client has a history of hypertension
Musculoskeletal
Right-sided lower extremity weakness is seen
Endocrine
The client has diabetes mellitus
Psychosocial
The client reports drinking one glass of wine each evening with dinner, no tobacco use, and a history of major depression; the client takes sertraline.
Laboratory Results
During Admission
Blood Chemistry.
Glucose: 72 mg/dL (4.0 mmol/L)
Sodium: 133 mEq/L (133 mEq/L)
Chloride: 101 mEq/L (101 mmol/L)
Potassium: 3.7 mEq/L (3.7 mmol/L)
Laboratory Test and Reference Range
Blood Chemistry.
Glucose 74-106 mg/dL (4.1-5.9 mmol/L)
Sodium 136-145 mEq/L (136-145 mmol/L)
Chloride 98-106 mEq/L(98-106 mmol/L)
Potassium 3.5-5.0 mEq/L (3.5-5.0 mmol/L
Diagnostic Results
Admission
CT scan of the head without contrast
1830:
No areas of hemorrhage are noted
Based on the clinical data, which condition should the nurse suspect?
- A. Bell palsy
- B. Guillain-Barré syndrome
- C. Ischemic stroke
- D. Seizure disorder
Correct Answer: C
Rationale: Sudden-onset right-sided facial drooping, slurred speech, arm drift, and leg weakness, with a non-hemorrhagic CT scan, strongly suggest ischemic stroke (C). Bell palsy (A) typically involves only facial weakness. Guillain-Barré (B) presents with ascending paralysis. Seizure disorder (D) lacks seizure activity in the history.
You may also like to solve these questions
The nurse in the emergency department is caring for a 62-year-old client.
Progress Notes
Emergency Department
0900: The client is brought to the emergency department by a family member after being found confused and lethargic. On arrival, the client is obtunded and does not respond to verbal stimuli.
Medical history includes major depressive disorder and chronic neck and back pain after a motor vehicle collision 2 years ago. The family member states that the client takes multiple medications but does not know which kind. The client was divorced a few months ago.
Physical examination shows 1-mm pupils, shallow breathing, and reduced bowel sounds. Fingerstick blood glucose is 78 mg/dL (4.3 mmol/L). ECG reveals normal sinus rhythm. Breath alcohol test is negative.
Vital signs: T 98.1 F (36.7 C), P 62, RR 8, BP 80/40, SpO, 94% on room air.
Select client findings that are most concerning to the nurse.
- A. The client is brought to the emergency department by a family member after being found confused and lethargic.
- B. The client is obtunded and does not respond to verbal stimuli.
- C. Medical history includes major depressive disorder and chronic neck and back pain after a motor vehicle collision 2 years ago.
- D. Physical examination shows 1-mm pupils, shallow breathing, and reduced bowel sounds.
- E. Fingerstick blood glucose is 78 mg/dL (4.3 mmol/L).
- F. Vital signs: T 98.1 F (36.7 C), P 62, RR 8, BP 80/40, SpO2 94% on room air.
Correct Answer: B,C,E,G
Rationale: B: Obtundation indicates severe CNS depression. C: Though listed as a choice, it repeats B and is likely a typo; assuming it refers to the same finding, it's concerning. E: Pinpoint pupils, shallow breathing, and reduced bowel sounds suggest opioid intoxication. G: Low BP and slow respiratory rate are life-threatening. A is less urgent, D is historical, and F is normal.
The nurse is caring for a 12-month-old male client.
History and Physical
Body System
General
The client is brought to the emergency department by the parents due to increased leg bruising and left knee swelling for 1 day; the parents report that the client seems more tired and less playful; both parents and the sister are healthy, but a maternal uncle died at age 7 after mild head trauma.
Integumentary
Good hygiene; no abrasions; no burns; bilateral scattered lower extremity bruising
Eye, Ear, Nose, and Throat (EENT)
The parents report that the client's gums have been bleeding when chewing on crackers
Pulmonary
Vital signs: RR 38, SpO 100% on room air, upper respiratory infection 3 weeks ago that completely resolved after 4 days.
Cardiovascular
Vital signs: T 98.7 F (37.1 C), P 136
Musculoskeletal
Left knee redness and swelling with limited range of motion; the client can bear weight on both lower extremities; the parents state the child has recently started learning to walk by holding onto furniture and sometimes falls
Genitourinary
The parents state that urine output has been normal; urine is clear and pale yellow; the penis is uncircumcised
Psychosocial
The client is cooperative during examination; the client appears appropriately dressed for the season and weather; the mother says the child has no interest in toilet-training.
Laboratory Results.
Laboratory Test and Reference Range
Hematology.
Hematocrit
1-6 years: 39% (0.39)
30%-40%:
(0.30-0.40)
WBC
<_ 2 years: 8000/mm3 (8.0 × 10%/L)
6200-17,000/mm3
(6.2-17.0 × 10°/L)
Platelets
150,000-400,000/mm3: 163,000/mm3 (163 × 10°/L)
(150-400 × 10°/L)
aPTT (Activated partial thromboplastin time)
30-40 sec: 60 sec
PT
11-12.5 sec: 12 sec
Factor VIII
55%-145%: 6%
Factor IX
60%-140%: 100%
Which of the following statements by the client's parent indicate teaching was effective? Select all that apply.
- A. I can provide over-the-counter ibuprofen as needed for pain.
- B. If we have another child, there is a chance the child could have hemophilia too.
- C. My child should avoid playing contact sports.
- D. Tingling in the joints can be a sign of joint bleeding.
- E. We will need preventive clotting medicine only before major surgeries.
Correct Answer: B,C,D
Rationale: B: Correct - Hemophilia A is X-linked, so future children may inherit it. C: Correct - Contact sports increase bleeding risk and should be avoided. D: Correct - Tingling indicates possible joint bleeding, requiring prompt attention. A: Incorrect - Ibuprofen can increase bleeding risk. E: Incorrect - Preventive factor replacement is often needed regularly, not just before surgeries.
The nurse is caring for a 25-year-old female client.
History and Physical
Body System
General
Client reports jitteriness, anxiety, and palpitations for the past 2 months. Fine hand tremor is noted. Client reports insomnia for approximately 1 week.
Integumentary
Client is diaphoretic.
Eye, Ear, Nose, andThroat (EENT)
Exophthalmos is noted. Goiter is present.
Gastrointestinal
Client reports 10 lb (4.5 kg) weight loss over the past month. Bowel sounds are normoactive. Client reports diarrhea for the past few days.
Reproductive
Last menstrual period was 3 months ago.
Vital Signs
T 99.2 F (37.3 C)
P 164
RR 22
BP 156/92
The nurse is reinforcing client teaching about home precautions following the first dose of RAI. For each nurse statement, click to specify whether the statement is appropriate or not appropriate to include in the teaching.
- A. Avoid sharing utensils with your spouse.
- B. It is safe to hold your child 2 hours after treatment.
- C. Delay pregnancy attempts for the next 4-6 months.
- D. Wash your clothes separately from those of others.
- E. You should sleep in a separate bedroom for 1-2 weeks.
Correct Answer: A,C,D,E
Rationale: A: Appropriate, as RAI can contaminate utensils, posing a radiation risk to others. B: Not appropriate, as close contact with children should be limited for several days post-RAI to minimize radiation exposure. C: Appropriate, as RAI can affect fertility and fetal health, requiring a delay in pregnancy. D: Appropriate, as washing clothes separately reduces the risk of radiation exposure to others. E: Appropriate, as sleeping separately minimizes radiation exposure to household members.
The nurse is caring for a 25-year-old female client.
History and Physical
Body System
General
Client reports jitteriness, anxiety, and palpitations for the past 2 months. Fine hand tremor is noted. Client reports insomnia for approximately 1 week.
Integumentary
Client is diaphoretic.
Eye, Ear, Nose, andThroat (EENT)
Exophthalmos is noted. Goiter is present.
Gastrointestinal
Client reports 10 lb (4.5 kg) weight loss over the past month. Bowel sounds are normoactive. Client reports diarrhea for the past few days.
Reproductive
Last menstrual period was 3 months ago.
Vital Signs
T 99.2 F (37.3 C)
P 164
RR 22
BP 156/92
Which clinical finding is most concerning at this time?
- A. Diarrhea
- B. Fine hand tremor
- C. Tachycardia
- D. Weight loss
Correct Answer: C
Rationale: Tachycardia (pulse 164) is most concerning as it may indicate severe hyperthyroidism or other cardiovascular issues requiring immediate intervention.
The nurse is caring for a 12-month-old male client.
History and Physical
Body System
General
The client is brought to the emergency department by the parents due to increased leg bruising and left knee swelling for 1 day; the parents report that the client seems more tired and less playful; both parents and the sister are healthy, but a maternal uncle died at age 7 after mild head trauma.
Integumentary
Good hygiene; no abrasions; no burns; bilateral scattered lower extremity bruising
Eye, Ear, Nose, and Throat (EENT)
The parents report that the client's gums have been bleeding when chewing on crackers
Pulmonary
Vital signs: RR 38, SpO 100% on room air, upper respiratory infection 3 weeks ago that completely resolved after 4 days.
Cardiovascular
Vital signs: T 98.7 F (37.1 C), P 136
Musculoskeletal
Left knee redness and swelling with limited range of motion; the client can bear weight on both lower extremities; the parents state the child has recently started learning to walk by holding onto furniture and sometimes falls
Genitourinary
The parents state that urine output has been normal; urine is clear and pale yellow; the penis is uncircumcised
Psychosocial
The client is cooperative during examination; the client appears appropriately dressed for the season and weather; the mother says the child has no interest in toilet-training
Which of the following laboratory tests does the nurse anticipate to help determine the cause of the client's condition? Select all that apply.
- A. Clotting factors VIII and IX
- B. CT scan of the head
- C. Echocardiogram
- D. Platelet count
- E. PTT
Correct Answer: A,D,E
Rationale: A: Anticipated - Testing for clotting factors VIII and IX is essential to diagnose hemophilia, given the symptoms and family history. D: Anticipated - Platelet count helps rule out thrombocytopenia as a cause of bleeding. E: Anticipated - PTT (partial thromboplastin time) assesses the intrinsic clotting pathway, which is prolonged in hemophilia. B, C: Not indicated as they do not directly assess bleeding disorders.