Nokea
History and Physical
Body System,Findings
General
Client has history of coronary artery disease, hypertension, hyperlipidemia, diverticulosis, and
osteoarthritis; Helicobacter pylori infection 2 years ago; client reports taking over-the-counter
ibuprofen every 8 hours for left knee pain for the past 2 weeks; daily medications include aspirin,
carvedilol, lisinopril, and atorvastatin
Neurological
Alert and oriented to person, place, time, and situation
Pulmonary
Vital signs: RR 20, SpO 96% on room air, lung sounds clear bilaterally; no shortness of breath;
client smokes 1 pack of cigarettes per day and smokes marijuana 1 or 2 times weekly
Cardiovascular
Vital signs: P 110, BP 90/62; no chest pain; S1 and S2 heard on auscultation; peripheral pulses
2+; client states feeling lightheaded and reports passing out about 1 hour ago
Gastrointestinal
Abdominal pain rated as 4 on a scale of 0-10; one episode of hematemesis; two episodes of
large, black, liquid stools in the morning
Musculoskeletal
Examination of the knees shows crepitus that is worse on the left; no swelling, warmth, or
erythema; range of motion is normal
Psychosocial
Client reports drinking 1 or 2 glasses of wine per day
Complete the following sentence/sentences by choosing from the list/lists of options.The licensed practical nurse should assist the registered nurse to prepare the client for emergency--------------------------
- A. colonoscopy
- B. CT angiography
- C. Esophagogastroduodenoscopy
Correct Answer: C
Rationale: The nurse should assist in preparing the client for emergency esophagogastroduodenoscopy (EGD). An EGD involves
passing an endoscope down the esophagus to visualize the upper gastrointestinal (Gl) structures (eg, esophagus, stomach,
duodenum), identify the source of the bleed, and perform interventions to stop the bleeding (eg, hemostatic clipping). To
prepare the client for EGD, the nurse should ensure NPO status has been initiated to reduce the risk of aspiration.
Interventions to stabilize the client (eg, IV fluids, blood transfusion) are often initiated before EGD.
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The nurse is caring for a 20-year-old client.
Progress Notes
Clinic Visit
For the past week, the client has experienced flu-like symptoms, including low-grade fevers, headaches, nausea, vomiting, and, today,
diarrhea and dark urine. The client reports widespread itching but has no rash. Skin and scleras are jaundiced. No lymphadenopathy
is present, and the abdomen is nondistended with a palpable liver edge. The client returned from an international mission trip a few
weeks ago.
Vital signs are T 99.9 F (37.7 C), P 88, RR 18, BP 128/80, and SpOz 98% on room air.
Laboratory Results
Laboratory Test and Reference Range ,Current
Liver Function Tests
Total bilirubin, Increased
Alkaline phosphatase, Increased
Aspartate aminotransferase (AST), Increased
Alanine aminotransferase (ALT) ,Increased
Complete the following sentence by choosing from the lists of options. The nurse suspects the client has ----------- and should implement ----------- precautions.
- A. Influenza
- B. Droplet
- C. Contact
- D. Standard
- E. Hepatitis A
Correct Answer: D,E
Rationale: Hepatitis A is an infection that leads to widespread inflammation of the liver. Transmission occurs through the fecal-oral route and is commo
in areas with overcrowding and poor sanitation. Outbreaks frequently result from contaminated water or food, and the condition is seen
primarily in resource-limited countries. Symptoms develop abruptly, initially including nausea, vomiting, anorexia, fever, and right upper
quadrant pain. A few days later, dark urine (bilirubinuria) and/or pale stools (lacking bilirubin pigment) may be seen. These are usually
followed by jaundice and pruritus. In addition, laboratory results show elevated liver function tests.
Hand hygiene, especially after toileting and before meals, is the most important intervention for reducing the risk of hepatitis A infection.
Therefore, for a client hospitalized with hepatitis A, standard precautions (ie, hand hygiene, disinfection of equipment and surfaces) must be
implemented to prevent transmission. Additional precautions (eg, disposable gown, gloves) should be used as needed (eg, during procedure
Nurses' Notes
Initial Clinic Visit
1100:
The client has experienced enuresis at night for the past 2 weeks and frequently requests to use the
bathroom while at school. The client was previously toilet trained with no nighttime bed wetting for 6 months;
the client recently relocated to a new home and school where the client lives with parents.
The parent reports that the client has recently demonstrated fatigue, irritability, and multiple behavioral
outbursts that resemble past temper tantrums. The client frequently reports feeling thirsty. No dysuria or
urinary hesitancy is reported.
Weight and height were in the 40th percentiles at the previous visit a year ago. Growth charts today show
the client's weight in the 20th percentile and height in the 40th percentile.
The client appears tired and irritable. Dry mucous membranes are noted with no increased work of
breathing. The lungs are clear to auscultation bilaterally. No cardiac murmur is heard.
Which of the following statements by the client's parent indicates a correct understanding of the teaching about management for type 1 diabetes mellitus? Select all that apply
- A. I may need to administer insulin more frequently when my child is ill
- B. Insulin requirements will change as my child grows
- C. Insulin should be injected deeply enough to reach the muscle
- D. Overnight social events should be avoided to prevent changes in my child's routine
- E. Proper diet and exercise can eliminate the need for insulin during adulthood.
Correct Answer: A,B
Rationale: Clients with type 1 diabetes mellitus (DM) have impaired insulin production due to autoimmune destruction of pancreatic beta
cells. Because clients with type 1 DM do not produce insulin, lifelong insulin replacement is required. Insulin requirements
will change with growth and development
Insulin requirements may increase because stressful events (eg, illness) cause blood glucose levels to rise. When the
client is ill, the parent should be instructed to notify the health care provider, monitor blood glucose levels closely, test the urine
for ketones, increase insulin administration per sliding scale, and monitor for signs of dehydration
History and Physical
Body System
Findings
General
Client reports a 1-week history of general malaise, fever and chills, night sweats, fatigue, and
poor appetite. Client has poorly controlled hypertension, hypercholesterolemia, and mitral
valve prolapse and regurgitation.
Eye, Ear, Nose, and
Throat (EENT)
Poor dental hygiene. Client reports having 2 teeth extracted 3 weeks ago.
Pulmonary
Vital signs are RR 18 and SpO, 96% on room air. Lungs are clear to auscultation bilaterally.
Cardiovascular
Vital signs are T 100.4 F (38 C), P 105, and BP 140/82. Sinus tachycardia with occasional
premature ventricular contractions on cardiac monitor. S1 and S2 heard on auscultation with
loud systolic murmur at the apex. Peripheral pulses 2+; no edema noted.
Integumentary
Small, erythematous macular lesions on both palms. Thin, brown longitudinal lines on several
nail beds.
The nurse has reviewed the information from the Diagnostic Results and Nurses' Notes. For each finding, click to specify whether the finding indicates that the client's status has not changed or has declined
- A. BP 102/70
- B. T 100.4 F (38 C)
- C. Peripheral pulses 1+
- D. Shortness of breath when recumbent
- E. Scattered crackles on lung auscultation
Correct Answer:
Rationale: Infective endocarditis (E) requires long-term antibiotic therapy (ie, 4-6 weeks). Fever (eg, T 100.4 F [38 C]) can persist for
several days despite appropriate antibiotic therapy.
In addition to the risk for systemic embolism (eg, stroke), clients with IE are at risk for heart failure if the involved valve
becomes dysfunctional. Decreased capillary oxygen saturation, shortness of breath when recumbent, and scattered
crackles on lung auscultation indicate fluid backup in the lungs. In addition, borderline low blood pressure (compared to
uncontrolled high blood pressure at admission) and decreased peripheral pulses (1+ vs 2+ on admission) indicate decreased
cardiac output and are concerning for heart failure.
Nurses' Notes
Outpatient Clinic
Initial
visit
The child recently started attending a new preschool and hit a teacher during lunch. The parent says, "My
child has never been aggressive before but has always been particular about food."
The client was born at full term without complications and has no significant medical history. The child
started babbling at age 6 months, and the parent reports that the first words were spoken around age 12
months. The client then became quiet and "obsessed" with stacking blocks and organizing toys by color.
The child can kick a ball, draw a circle, pedal a tricycle, and now says two-word phrases. Vitals signs are
normal, and the client is tracking adequately on growth curves.
During the evaluation, the child sits in the corner of the room playing with blocks. The client does not follow
the parents gaze when the parent points to toys in the office. The child begins screaming and rocking back
and forth when the health care provider comes near.
The client returns to the clinic 6 months after starting behavioral therapy. Which statement by the parent indicates a need for further therapy?
- A. My child will eat but only if I cook the same meal every day.
- B. My child will make only brief periods of eye contact with the teacher.
- C. My child will occasionally play with other children at the park.
- D. My child will squeeze a soft toy instead of banging the head.
Correct Answer: A
Rationale: Early childhood intervention programs (eg, behavioral therapy) are a critical component for clients with autism spectrum
disorder and can have positive long-term effects on presenting symptoms and social skills. Therapy helps increase
communication and language skills; improve focus, social skills, memory, and academic functioning; and decrease problematic
behaviors through positive reinforcement and other behavioral approaches
When evaluating the outcomes of therapy, the nurse should recognize that clients who demonstrate narrowed, restricted
interests (eg, eating the same foods) indicate a need for additional therapy
History
Emergency Department
Admission: The client is brought to the emergency department for psychiatric evaluation after being found on the
roof of a seven-floor office tower screaming, "I am going to jump! Life is not worth living anymore!" The
client admits having attempted to jump off the building and wishes the police had not intervened. The
client reports that thoughts of self-harm have increased in intensity since a divorce 2 months ago. The
client's thoughts of self-harm are intermittent, with no reports of suicidal thoughts at the present time.
The client reports losing 10 pounds in the past month without trying, difficulty concentrating on tasks,
and feeling tired most of the day. No history of violence or trauma. The client reports recurring feelings
of worthlessness but no auditory/visual hallucinations or homicidal ideations.
Medical history includes seizures, but the client has not been taking prescribed levetiracetam. The client
reports smoking 1 pack of cigarettes per day for the past 3 years.
Vital signs: T 97.2 F (36.2 C), P 100, BP 153/70, RR 19
Laboratory Results
Laboratory Test and Reference Range,Admission
Urine drug screen
Cocaine
Negative
Positive,
Opioid
Negative
Negative,
Amphetamines
Negative
Negative,
Marijuana
Negative
Positive,
Phencyclidine
Negative
Negative,
Benzodiazepines
Negative
Negative,
Barbiturates
Negative
Negative,
Breathalyzer
No alcoho detected
0.00
Nurses' Notes
Inpatient: Mental Health Unit
0900:
1200:
1500:
2000:
The client is inattentive, withdrawn, and depressed with low energy. The client's appearance is disheveled
with noted body odor. The client is declining breakfast and does not participate in group therapy. Education
was provided about the importance of participating in the treatment plan, and the client was encouraged to
shower.
The client is observed pacing back and forth in the room. The client is visibly upset and tearful and states, "I
can't live like this anymore. Everything in my life is going wrong." The client is encouraged to use deep
breathing and relaxation techniques to ease anxiety.
The client remains isolated to the room, pacing back and forth. The client rates depression as 6 on a scale of
0-10 and anxiety as 5 on a scale of 0-10.
The client was observed collecting blankets and storing them in the room behind the bed. When
approached, the client became defensive.
The nurse is caring for the client 4 days after admission. For each finding below, click to specify if the finding indicates that the client's status is improving or concerning.
- A. Client ate 80% of the meals and took a shower today.
- B. Client is seen joining group activities in the day room.
- C. Client states, "I feel more energetic today than I have in many months."
- D. Client is seen handing a personal watch and photo album to another client.
- E. Client reports depression 0/10 and states, "I feel a lot better. I think I know what I need to do now."
Correct Answer:
Rationale: Participation in group activities, increased appetite, and performing self-hygiene (eg, showering) indicate an
improvement in the client's status because the client was previously withdrawn with little interest in interacting with others or
performing self-care (eg, declining breakfast tray, body odor).
During the early phase of therapy with antidepressants (eg, selective serotonin reuptake inhibitors [escitalopram]), the risk of
suicide may increase because clients can become more energized as the depression lifts, enabling them to carry out previous
suicide plans. The nurse should find concerning the client's statements about feeling more energized and "knowing what to
do now," which can indicate that the client has determined a plan for suicide and is at peace knowing the plan.
Giving away meaningful possessions (eg, watch, photo album) is concerning for an impending suicide attempt. The nurse
should ask directly about thoughts of suicide.