Nokea
The nurse is caring for a 16-year-old client.
History and Physical Laboratory Results
Body System- Findings
General- The client comes to the emergency department with pain in the upper back, both knees, and the lower legs that is rated as 9 on a scale of 0-10; medical history includes sickle cell disease; the client reports attending an outdoor sports camp for the past 4 days; the client appears restless with frequent position changes and facial grimacing
Neurological- The client is alert and oriented to person, place, and time
Pulmonary- Vital signs: RR 24, SpOz 95% on room air, breath sounds are clear bilaterally Cardiovascular- Vital signs: T 98.4 F (36.9 C), P 120, BP 130/78; S1 and S2 are auscultated with no murmurs, continuous cardiac monitor shows sinus tachycardia
Gastrointestinal- The abdomen is soft and nontender with normal bowel sounds; the client vomited 30 mL of clear liquid
Musculoskeletal- The client has multiple, tender, bony points
Genitourinary- The client voided 50 mL of clear, amber-colored urine
Click to highlight below the 2 prescriptions the nurse should implement first.
- A. Administer morphine
- B. Administer hydroxyurea PO
- C. Apply moist heat to knees
- D. Encourage incentive spirometer
- E. Continuous IV fluids
- F. Record strict intake and output
Correct Answer: A,E
Rationale: Morphine and IV fluids are prioritized to relieve pain and improve hydration in a sickle cell crisis.
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The nurse is caring for a 75-year-old female client. Nurses' Notes Laboratory Results Diagnostic Results Emergency Department
The client is transferred to the emergency department from a skilled nursing facility for a 3-day history of left lower quadrant abdominal pain rated 8 on a scale of 0-10, loss of appetite, and nausea. Although the client has a history of chronic constipation, she has had 2 or 3 loose stools daily for 1 week. The client reports tenderness on deep palpation of the left lower quadrant. There is an area of blanchable redness on the coccyx. The stool is positive for occult blood.
The client has residual left-sided weakness from an ischemic stroke 2 years ago and ambulates with a walker. The client reports falling several times in the past 6 months; the last fall was 3 weeks ago No ecchymosis or injuries are noted. The client had a hysterectomy and salpingo-oophorectomy for uterine fibroids 20 years ago. Vital signs are T 100 F (37.8 C), P 98, RR 17, BP 126/68, and SpOz 97% on room air.
Medical-Surgical Unit: 4 Days Later
The client continues to experience left lower quadrant pain, decreased appetite, and nausea. Today, she developed chills. Stool frequency has not increased. Severe tenderness is noted in the left lower quadrant, and a mass is palpable. Vital signs are T 101.3 F (38.5 C), P 112, RR 17, BP 110/80, SpO, 97% on room air.
Complications associated with acute diverticulitis include ........, ........ and ........
- A. Pyelonephritis
- B. Fistula formation
- C. Bowel perforation
- D. Abscess formation
- E. Rupture of the appendix
Correct Answer: B,C,D
Rationale: Diverticulitis complications include fistula , perforation , and abscess .
The nurse is caring for a 68-year-old client who is brought to the emergency department due to confusion.
History and Physical Body System Findings
General- Client's adult child reports the confusion started this morning, following 3 days of fever and productive cough; medical history includes small bowel resection 10 days ago, chronic heart failure, and coronary artery disease
Neurological- Client is drowsy and oriented to person only, but intermittently agitated Integumentary- Small abdominal surgical incision is present over lower left quadrant, edges are well approximated, and no redness or drainage is noted
Pulmonary- Vital signs are RR 24 and SpO 90% on room air; labored breathing is observed, and crackles and diminished breath sounds are auscultated over right lower chest; client is expectorating yellow sputum; history includes smoking a pack of cigarettes daily for the past 40 years
Cardiovascular- Vital signs are T 102.9 F (39.4 C), P 110, and BP 110/70; S1 and S2 are heard on auscultation; bilateral lower extremity edema is 1+; ECG shows sinus tachycardia
Gastrointestinal- Normoactive bowel sounds are auscultated; client's last bowel movement was 1 day ago
Genitourinary- Client voided concentrated yellow urine
For each potential intervention, click to specify if the intervention is expected or unexpected for the care of the client.
- A. Administer antipyretics
- B. Administer IV antibiotics
- C. Implement strict bed rest
- D. Implement NPO restrictions
- E. Implement airborne precautions
- F. Prepare client for bedside thoracentesis
- G. Administer oxygen to maintain SpO2 ≥ 95%
Correct Answer: A,B,G
Rationale: Antipyretics , antibiotics , oxygen are expected for pneumonia. Bed rest , NPO , isolation , and thoracentesis are not routine.
The nurse is caring for a 63-year-old client.
Progress Notes
Emergency department
1 week ago: The client is admitted to the hospital with dyspnea, orthopnea, and bilateral leg swelling. The client has hypertension, heart failure, and chronic kidney disease. Medications include furosemide, hydrochlorothiazide, lisinopril, and metoprolol.
Clinic visit
Today: The client was recently discharged from the hospital after treatment for acute heart failure. Symptoms improved after treatment with diuretics. Today, the client reports new-onset muffled hearing and difficulty understanding speech. Examination shows bilateral hearing loss.
Which medication should the nurse clarify with the health care provider?
- A. Furosemide
- B. Hydrochlorothiazide
- C. Lisinopril
- D. Metoprolol
Correct Answer: A
Rationale: Furosemide is associated with ototoxicity, which may cause hearing loss, requiring clarification.
Emergency Department
0800: A 43-year-old client comes to the emergency department due to lower
back pain and bilateral leg weakness. The client reports that the
weakness began 3 days ago in the feet and has gradually worsened.
The client sought treatment today after becoming "so weak that I fell
while walking" and noticing new hand weakness and difficulty
swallowing. Back pain radiates down both legs and is rated as 5 on a
scale of 0-10. The client recently recovered from an illness with flu-like
symptoms. The client reports a history of hypertension and takes no
medications. Assessment of the lower extremities reveals muscle
strength of 2/5 and decreased sensation to pinprick. Achilles tendon
and patellar reflexes are decreased.
1000:
The client reports difficulty raising the arms and inability to squeeze the
fingers. The client reports chest tightness and difficulty breathing.
1030:
The client is breathless while speaking. Respirations are shallow and
labored. The client is diaphoretic. The skin is pale and cool. No
audible wheezing or stridor is present.
Which of the following statements by the client's spouse indicate that the teaching has been effective? Select all that apply.
- A. My children and I need to get tested because we could become paralyzed, too.'
- B. My spouse may have neurologic deficits for several months.'
- C. My spouse may need a temporary feeding tube for nutrition while on the ventilator.'
- D. Our children should refrain from getting a yearly flu vaccine.'
- E. This was most likely triggered by the recent flu-like illness.'
Correct Answer: B,C,E
Rationale: Prolonged deficits , feeding tube need , and viral trigger are accurate. GBS is not contagious , and flu vaccines are recommended.
The nurse is caring for a 75-year-old female client. Nurses' Notes Laboratory Results Diagnostic Results Emergency Department
The client is transferred to the emergency department from a skilled nursing facility for a 3-day history of left lower quadrant abdominal pain rated 8 on a scale of 0-10, loss of appetite, and nausea. Although the client has a history of chronic constipation, she has had 2 or 3 loose stools daily for 1 week. The client reports tenderness on deep palpation of the left lower quadrant. There is an area of blanchable redness on the coccyx. The stool is positive for occult blood.
The client has residual left-sided weakness from an ischemic stroke 2 years ago and ambulates with a walker. The client reports falling several times in the past 6 months; the last fall was 3 weeks ago No ecchymosis or injuries are noted. The client had a hysterectomy and salpingo-oophorectomy for uterine fibroids 20 years ago. Vital signs are T 100 F (37.8 C), P 98, RR 17, BP 126/68, and SpOz 97% on room air.
Medical-Surgical Unit: 4 Days Later
The client continues to experience left lower quadrant pain, decreased appetite, and nausea. Today, she developed chills. Stool frequency has not increased. Severe tenderness is noted in the left lower quadrant, and a mass is palpable. Vital signs are T 101.3 F (38.5 C), P 112, RR 17, BP 110/80, SpO, 97% on room air.
For each potential intervention, click to specify the intervention is expected or not expected for the care of the client at this time.
- A. Keep NPO
- B. Maintain IV fluids
- C. Administer antibiotics
- D. Apply heating pad to abdomen
- E. Verify consent for abdominal surgery
Correct Answer: A,B,C
Rationale: NPO status , IV fluids , and antibiotics are expected for acute diverticulitis. Heating pads worsen inflammation, and surgery is not immediate.