Nokea
History and Physical
Nurses' Notes
Flow Sheet
Vital signs
The client is a 9-month-old male who was born by cesarean section at 32 weeks gestation. He has been hospitalized once with respiratory syncytial virus at 2 months of age. He is up to date on vaccines.
Exhibits
Review H and P, nurse's note, and flow sheet.
Complete the diagram by specifying which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
- A. Remove some of the baby's clothing
- B. Clean the area with warm water
- C. Alert child protective services
- D. Swab the area and send for a culture
- E. Hold the vaccines
- F. Temperature
- G. Parent's understanding of education
Correct Answer: A,B
Rationale: Miliaria, caused by overdressing, is addressed by removing clothing and cleaning with warm water. Monitoring temperature and parental education prevents recurrence.
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History and Physical
Nurses' Notes
Flow Sheet
Laboratory Results
38-year-old primiparous client is seen in the outpatient obstetric office 2 weeks postpartum after a spontaneous vaginal birth of a full-term infant after rupture of membranes for 16 hours. The client was discharged on day 2, exclusively breastfeeding.
For each assessment finding, click to indicate whether findings from this client's assessment are generally associated with mastitis, endometritis, or could be a sign of both conditions.
- A. Pulse of 105 beats/minute - Both mastitis and endometritis
- B. Feeling chilled, achy, and fatigued - Both mastitis and endometritis
- C. Baby fed pumped breast milk - Mastitis
- D. Pain rating of 4 on a 0 to 10 scale - Mastitis
- E. Foul-smelling lochia rubra at 2 weeks postpartum - Endometritis
- F. Temperature of 101.2° F (38.4°C) - Both mastitis and endometritis
Correct Answer: B,D
Rationale: Tachycardia, chills, aches, fatigue, and fever are systemic signs of infection in both mastitis and endometritis. Feeding pumped milk and localized breast pain suggest mastitis due to milk stasis. Foul-smelling lochia is specific to endometritis, indicating uterine infection.
The nurse is caring for a child with a unilateral long-leg cast applied for the correction of club foot. Which action is most important for the nurse to perform?
- A. Palpate femoral pulses.
- B. Compare temperature of both legs.
- C. Monitor capillary refill of the toes.
- D. Examine for spontaneous movement.
Correct Answer: C
Rationale: Monitoring capillary refill ensures adequate circulation in the casted limb, detecting complications like compartment syndrome.
Which drink choice on a hot day indicates to the nurse that an adolescent with sickle cell anemia understands dietary considerations related to the disease?
- A. Diet cola.
- B. Ice tea.
- C. Lemonade.
- D. Milkshake.
Correct Answer: C
Rationale: Lemonade, a hydrating, caffeine-free drink, prevents dehydration, reducing sickling risk in sickle cell anemia.
An adolescent with pelvic inflammatory disease (PID) is admitted to the hospital after 14 days of taking levofloxacin 500 mg PO daily and metronidazole 500 mg IV piggy back (IVBP) twice daily (BID). She asks the nurse, 'Why do I have to be in the hospital? Why can't I get my treatment at home?' Which purpose should the nurse provide that supports an effective outcome?
- A. Detection of early symptoms of Jarisch-Herxheimer reaction.
- B. Collection of serial anaerobic cultures of vaginal discharge.
- C. Implementation of contact precautions to prevent spread of infection.
- D. Administration of a supervised parenteral antibiotic protocol.
Correct Answer: D
Rationale: Hospitalization ensures supervised IV antibiotics for severe PID unresponsive to outpatient therapy, preventing complications like tubo-ovarian abscess.
History and Physical
Nurses' Notes
Orders
The client is a 4-month-old female with a history of gastroesophageal reflux (GERD). Client had fundoplication surgery and will be hospitalized for several days of recovery.
Which are the 3 most likely reasons that the infant is crying?
- A. Hunger
- B. Opioid withdrawal
- C. Hemorrhage
- D. Separation anxiety
- E. Pain
- F. Hypovolemia
- G. Hypoxia
Correct Answer: A,E,F
Rationale: Hunger due to NPO status, postoperative pain, and hypovolemia from surgical fluid losses are likely causes of crying. No evidence supports withdrawal, hemorrhage, anxiety, or hypoxia.