Click to highlight below the assessment findings that requir...

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"

Click to highlight below the assessment findings that require immediate follow-up?

A. 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
B. Alert and oriented to person, place, and time; no neurologic deficits
C. Vital signs: RR 30, SpO2 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
D. 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 seconds; mild finger clubbing noted
E. 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'

Correct Answer: A,C,D,E

Rationale: Findings A, C, D, and E indicate urgent issues: shortness of breath with a history of cystic fibrosis , low oxygen saturation and respiratory distress , fever and tachycardia , and malabsorption symptoms require immediate intervention.

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

Based on the clinical findings, the nurse should be most concerned about which 3 potential complications?

A. Acute respiratory distress syndrome
B. Deep venous thrombosis
C. Pressure injury
D. Sepsis
E. Urinary tract infection

Correct Answer: A,D

Rationale: Pneumonia risks include ARDS and sepsis due to infection and respiratory compromise.

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 .

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.

Click to highlight below the 3 findings that should concern the nurse.

A. The client was diagnosed with gestational diabetes mellitus and prescribed insulin, but she reports not taking the insulin.
B. The client reports cigarette smoking (3-5 cigarettes/day) but denies alcohol or recreational drug use.
C. The client received treatment for bacterial vaginosis during the second trimester.
D. The client has gained 55 lb (25 kg) during the pregnancy. Group B Streptococcus result is negative.

Correct Answer: A,B,D

Rationale: Non-compliance with insulin , smoking , and excessive weight gain increase neonatal risks.

Which of the following complications is the newborn at increased risk for based on the maternal hist Select all that apply.

A. Brachial plexus injury
B. Cephalohematoma
C. Hypoglycemia
D. Neonatal sepsis
E. Polycythemia

Correct Answer: A,C,E

Rationale: Gestational diabetes and smoking increase risks for brachial plexus injury , hypoglycemia , and polycythemia .

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 â‰¥ 95%

Correct Answer: A,B,G

Rationale: Antipyretics , antibiotics , oxygen are expected for pneumonia. Bed rest , NPO , isolation , and thoracentesis are not routine.