Click to highlight below the 4 findings that require immedia...

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 4 findings that require immediate follow-up.

A. 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
B. The client appears restless with frequent position changes and facial grimacing
C. Vital signs: RR 24, SpO2 95% on room air; breath sounds are clear bilaterally
D. 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
E. The client vomited 30 mL of clear liquid
F. The client has multiple, tender, bony points
G. The client voided 50 mL of clear, amber-colored urine

Correct Answer: A,B,D,F

Rationale: Severe pain , distress signs , tachycardia , and bony tenderness indicate a sickle cell crisis, requiring urgent management.

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

For each potential intervention, click to specify if the Intervention is indicated or not indicated for the care of the client.

A. Initiate seizure precautions
B. Encourage frequent ambulation
C. Start a magnesium sulfate infusion
D. Prepare to administer antihypertensives

Correct Answer: A,C,D

Rationale: Seizure precautions , magnesium sulfate , and antihypertensives are indicated for preeclampsia with severe features. Ambulation is not prioritized due to risk of falls.

The client is most likely experiencing ....... and is at risk for.......

A. Osteomyelitis
B. Rhabdomyolysis
C. Sickle acute cell pain episode
D. Sepsis
E. Ischemic organ damage
F. Compartment syndrome

Correct Answer: C,E

Rationale: Severe pain and tachycardia suggest a sickle cell pain episode , with risk for ischemic organ damage due to vaso-occlusion.

The nurse is caring for a 6-year-old client accompanied by the parents.
History and Physical
Body System
Findings
General
Client is brought to the emergency department due to
shortness of breath; medical history includes cystic fibrosis
and many previous hospital admissions for pneumonia; in the
3rd percentile for height and weight
Neurological
Alert and oriented to person, place, and time; no neurologic
deficits
Pulmonary
Vital signs: RR 30, SpO, 87% on room air; moderate
subcostal retractions; bilateral wheezing and coarse crackles
throughout lung fields with fine inspiratory crackles at left lung
base; paroxysmal coughing that produces thick, yellow,
blood-tinged sputum; parents report that the client has begun
to become "winded" after showering and other activities Cardiovascular
Vital signs: T 101.7 F (38.7 C), P 130, BP 94/58; skin warm
and dry; peripheral pulses palpable 2+; capillary refill 3
econds; mild finger clubbing noted
Gastrointestinal
Abdomen soft with normoactive bowel sounds; parent states,
"Swallowing the enzyme capsules is very difficult for my child,
and I have noticed an increase in greasy, bulky stools"

Which of the following parent statements indicate a correct understanding? Select all that apply.

A. A low-fat diet will help normalize my child's stool.'
B. I will encourage my child to get regular exercise.'
C. I will make sure that my child receives the flu vaccine each year.'
D. My child should perform daily breathing exercises, even if there are no symptoms.'
E. My child will require lifelong vitamin supplementation.'
F. The pancre-lipase capsules can be opened and sprinkled on food.'

Correct Answer: B,C,D,E,F

Rationale: Exercise , flu vaccine , daily breathing exercises , vitamin supplementation , and sprinkling pancre-lipase are correct. A low-fat diet is incorrect; a high-calorie, high-fat diet is needed for cystic fibrosis.

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 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.

For each finding, click to specify whether the finding indicates that the client's status has improved or not improved.

A. Client is seen talking alone in the hallway
B. Client is seen playing board games with peers
C. Client asks the technician for hygiene supplies
D. Client states, 'The voices are a part of my illness.'
E. Client refuses to take medication from a new nurse
F. Client is willing to eat food that is prepackaged only

Correct Answer: B,C,D

Rationale: Social interaction , hygiene requests , and insight into illness show improvement. Talking alone , medication refusal , and food paranoia indicate ongoing symptoms.