Nokea
A nurse is planning care for a client who was recently admitted to the
medical-surgical unit.
Diagnostic Results
Day 1:
WBC count 4,500/mm³ (5,000 to 10,000/mm³)
RBC count 3.2 million/mm³ (4.2 to 5.4 million/mm³)
Hgb 11 g/di (12 to 16 g/dL)
Hct 46% (37% to 47%) '
Platelet count 145,000/mm³ (150,000 to 400,000/mm³)
Erythrocyte sedimentation rate 40 mm/hr (up to 20 mm/hr)
Urinalysis:
pH 5.0 (4.6 to 8.0)
Specific gravity 1.0 (1.010 to 1.025)
Protein 10 mg/dL (0 to 8 mg/dL)
Glucose negative (Negative)
WBC casts 2 (0 to 4 per low-power field)
Admission Assessment
Client reports new onset of fever and discomfort in their joints and increase malaise. No relevant
medical history. Client is alert to person, place, time, and situation. Reports generalized pain as 4
on a scale of 0 to 10. Macular rash present on cheeks bilateral. Lungs clear anterior and posterior.
Bowel sounds active in all 4 quadrants. Last bowel movement 1 day ago. Skin warm, dry, and
intact. Capillary refill less than 3 seconds. A 20-gauge IV saline lock inserted in back left hand
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing.
- A. Anticipate administering prescribed immunosuppressant medications
- B. Ensure that client has intake of at least 200 ml/hr
- C. Encourage client to avoid direst sunlight
- D. Initiate contact precautions
- E. Prepare client for light therapy
- F. Sickle cell crisis
- G. Psoriasis
Correct Answer: B,E
Rationale: Systemic lupus erythematosus is indicated by the lab results and symptoms.
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A nurse is caring for a client of a psychiatric unit
Nurses' Notes
0700
Client is admitted to the unit. They deny suicidal ideations at this time. Client states, "I am an
assistant to a powerful spirit." Client is poorly groomed and has body odor.
0900:
Called to the client's room, Client states, "I cannot believe you put me in a room with spiders on
the wall. " Client requests immediate transfer to another room.
1200:
Psychiatrist is at the bedside evaluating the client. After history and physical, psychiatrist states
that they have diagnosed the client with schizophrenia.
Client is to be started on medication and milieu therapy History and
Physical
0700
Majority of client's history is obtained from client's parent who presents with client today.
According to the parent, client has been acting strangely for a few months. Client's symptoms
have been progressively worsening.
In the last month, the client has been seeing things that are not present and believes that they are
in a close relationship with "a powerful spirit." Client has not been bathing regularly for the last
few weeks.
Client has no significant health history. Client reports that they do not take illicit substances or
drink alcohol. Client's grandparent has a history of schizophrenia
For each potential action, click to specify if the action is indicated or contraindicated for the client.
- A. Allow the client to watch TV at high volume
- B. Ask the client about the content of their hallucinations
- C. Instruct the client on expected hygiene practices
- D. Assess the client for suicidal ideation
- E. Place the client in a room near the activity room
Correct Answer: B,D
Rationale: [
B: Asking the client about the content of their hallucinations is indicated to gather important information for assessment and treatment planning.
D: Assessing the client for suicidal ideation is crucial to ensure their safety and provide appropriate interventions.
A: Allowing the client to watch TV at high volume is contraindicated as it may exacerbate symptoms or disturb others.
C: Instructing the client on expected hygiene practices may not be a priority compared to assessing hallucinations and suicidal ideation.
E: Placing the client in a room near the activity room is not mentioned in the question and does not address the client's immediate needs.]
A nurse in a clinic is planning care for a child who has ADHD and is taking atomoxetine
Which of the following laboratory values should the nurse monitor?
- A. Liver function tests
- B. kidney function tests
- C. hemoglobin and hematocrit
- D. serum sodium and potassium
Correct Answer: A
Rationale: The correct answer is A: Liver function tests. Monitoring liver function is crucial as it assesses the health of the liver, detecting any abnormalities or diseases. Liver function tests include assessing levels of enzymes, proteins, and bilirubin. Abnormal results can indicate liver damage or dysfunction. Monitoring kidney function (B) is important but not the priority in this scenario. Hemoglobin and hematocrit (C) are essential for assessing blood health but not specific to liver function. Serum sodium and potassium (D) are more related to electrolyte balance than liver function.
A nurse is assessing a child who has bacterial pneumonia.
Which of the following manifestations should the nurse expect?
- A. Fever
- B. Bradycardia
- C. Dry skin
- D. Decreased respiratory rate
Correct Answer: A
Rationale: The correct answer is A: Fever. When the body is fighting an infection or inflammation, fever is a common manifestation due to the release of pyrogens that reset the body's temperature. Bradycardia (B) is a slow heart rate, not typically associated with infection. Dry skin (C) is more indicative of dehydration or a skin condition. Decreased respiratory rate (D) is not a common manifestation of infection. In this case, fever is the most expected manifestation due to the body's response to an infection.
A nurse is assessing the fontanels of 8-month-old infant.
which of the following findings should the nurse recognize as an expected finding?
- A. The anterior fontanel is open
- B. The posterior fontanel is open
- C. The anterior fontanel is sunken
- D. The anterior fontanel is bulging
Correct Answer: A
Rationale: The correct answer is A: The anterior fontanel is open. This is an expected finding in infants as the anterior fontanel typically remains open until around 18-24 months of age, allowing for the growth and expansion of the skull bones. It is a normal part of development and closure indicates maturation. The posterior fontanel closes earlier than the anterior fontanel, so option B is incorrect. Option C, sunken anterior fontanel, indicates dehydration, while option D, bulging anterior fontanel, is a sign of increased intracranial pressure, both of which are abnormal findings.
A nurse is teaching dietary guidelines to a client who has celiac disease.
Which of the following food choices is appropriate for this client?
- A. Canned barley soup
- B. Potato pancakes.
- C. Wheat crackers
- D. White flour tortillas
Correct Answer: B
Rationale: The correct answer is B: Potato pancakes. This choice is appropriate as it is likely to be well-tolerated by the client. Potatoes are a good source of carbohydrates and can provide energy. Additionally, potato pancakes are easy to digest and can be a good option for someone with digestive issues. On the other hand, A, C, and D contain grains that may be harder to digest for some individuals, especially if they have digestive concerns. Canned barley soup (A) may also contain added preservatives and sodium, which may not be ideal for the client's condition. Wheat crackers (C) can be high in fiber and may be difficult to digest. White flour tortillas (D) are made from refined grains and may not provide the necessary nutrients for the client.