Nokea
The nurse is performing a home health visit for an 84-year-old male.
History and Physical
Body System, Findings
General,
Client reports a 1-month-long history of fatigue and dyspnea that has worsened; he is unable to lie
flat and sleeps in a chair at night, medical history includes myocardial infarction, chronic heart
failure, chronic obstructive pulmonary disease, hypertension, and type 2 diabetes mellitus; client
was diagnosed with benign prostatic hyperplasia 8 months ago; client is adherent with prescribed
medications; client reports frequent consumption of donuts, hamburgers, steak, and fried chicken;
BMI is 34 kg/m?; client reports 6-Ib (2.7-kg) weight gain in 1 week
Neurological,
Alert and oriented to person, place, time, and situation
Pulmonary,
Vital signs: RR 24, SpOz 88% on room air; labored breathing, crackles in bilateral lung bases; client
expectorates frothy, pink-tinged sputum; client has a 40-year history of smoking 1 pack of cigarettes
per day
Cardiovascular,
Vital signs: T 98.8 F (37.1 C), P 98, BP 113/92; S1, S2, and S3 present; 3+ bilateral lower extremity
edema
Genitourinary, Concentrated yellow urine; client reports increased urinary hesitancy and urgency
Psychosocial,
Client reports being lonely and has depressed mental status
Prescriptions
Home Medication Record
Medication, Scheduled
Pravastatin 20 mg PO once daily, 2100
Furosemide 40 mg PO once daily, 0900
Tamsulosin 0.4 mg PO once daily, 0900
Potassium chloride 20 mg PO once daily, 0900
Metformin 1000 mg PO bid, 0900, 2100
Carvedilol 6.25 mg PO bid;hold for systolic blood pressure ≤100 mm Hg and/or HR <65/min, 0900, 2100
Sacubitril 97 mg/valsartan 103 mg PO bid, 0900, 2100
Drag words from the choices below to fill in the blank/blanks.The nurse recognizes that furosemide was effective as evidenced by------------,-----------------, and ------------------
- A. 2+ peripheral edema
- B. Increased urine output
- C. Reduced urinary hesitancy
- D. Reduced cholesterol level
- E. Reduced work of breathing
Correct Answer: A,B,E
Rationale: Loop diuretics (eg, furosemide) block renal reabsorption of sodium, chloride, and potassium, which increases fluid excretion
in the urine (ie, diuresis). Diuresis decreases intravascular volume, resulting in decreased peripheral edema (eg, from 3+ to
2+). In addition, as fluid volume decreases, pulmonary congestion improves, thereby resulting in improved oxygen exchange
and reduced work of breathing
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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 2-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 parent's 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.
Emergency Department
3 years The client is brought to the emergency department by the parents, who report that the child became upset
later
and started banging the head against the wall several times. The parents report that the client has had
these episodes frequently; however, this time, the child was injured. The client has a laceration on the
forehead and is admitted for 24-hour observation.
The client is newly prescribed aripiprazole for autism spectrum disorder. The nurse is reinforcing teaching to the client's parents. Which statement by the nurse is appropriate?
- A. Abruptly stopping the medication can cause withdrawal symptoms
- B. Aripiprazole will cure your child's autism.
- C. Restlessness is an expected side effect and will eventually subside.
- D. This medication will eliminate your child's self-harm behaviors
Correct Answer: A
Rationale: Aripiprazole, an atypical antipsychotic medication, is used in the treatment of irritability associated with autism spectrum
disorder (ASD), schizophrenia, bipolar disorder, and other mental health disorders. Aripiprazole works as a partial agonist at
the serotonin and dopamine receptor sites. As a result, the medication has a more favorable safety profile (eg, fewer metabolic
effects, lower potential for prolactin release) than other antipsychotics; however, it may be less effective in symptom relief.
Clients taking aripiprazole should be reminded to not abruptly stop taking the medication because it can cause withdrawal
symptoms (eg, anxiety, dizziness, tachycardia, diaphoresis, insomnia, vomiting) and may exacerbate previous symptoms.
These medications should be weaned over time and substituted with an alternate medication under the supervision of a health
care provider
The nurse is caring for a 24-year-old client.
Nurses' Notes
Emergency Department
1300:
The client is brought to the emergency department after a motor vehicle collision in which the driver's side airbag deployed.
The client was driving the vehicle and was not restrained by a seat belt. The client reports shortness of breath and chest
pain on inspiration and expiration.
History and Physical
Body System ,Findings
Neurological,
Awake, alert, and oriented to person; pupils equal, round, and reactive to light and accommodation; client is
agitated and moves all extremities spontaneously but does not follow commands
Integumentary, Superficial lacerations to the face; diffuse bruising noted on upper extremities and chest wall
Pulmonary,
Vital signs: RR 30, SpOz 92% via nonrebreather mask; unilateral chest wall expansion observed on inspiration;
left-sided tracheal deviation noted; breath sounds diminished throughout the right lung field
Cardiovascular,
Vital signs: P 104, BP 90/58; S1 and S2 heard on auscultation; all pulses palpable; no extremity peripheral edema
noted
Psychosocial ,Alcohol odor noted on the client's breath
Which of the following findings are consistent with a tension pneumothorax? Select all that apply.
- A. Diminished breath sounds on one side
- B. Dyspnea
- C. Hypotension
- D. Recent thoracic trauma
- E. Tracheal deviation
- F. Unilateral chest wall expansion
Correct Answer: A,B,C,D,E,F
Rationale: A pneumothorax is characterized by air inside the pleural space, which disrupts the negative pressure that maintains lung expansion. This
causes the lung to collapse either partially or completely, leading to unilateral, diminished breath sounds; unilateral chest wall
expansion; and dyspnea. A pneumothorax often occurs from blunt thoracic trauma (eg, during a motor vehicle collision). Air can also ent
the pleural space through the chest wall and parietal pleura (open pneumothorax) during or after an invasive procedure on or near the chest
wall (eg, thoracentesis, paracentesis, central line insertion) (Options 1, 2, 4, and 6).
The nurse is caring for a 24-year-old client.
Nurses' Notes
Emergency Department
1300:
The client is brought to the emergency department after a motor vehicle collision in which the driver's side airbag deployed.
The client was driving the vehicle and was not restrained by a seat belt. The client reports shortness of breath and chest
pain on inspiration and expiration.
History and Physical
Body System ,Findings
Neurological,
Awake, alert, and oriented to person; pupils equal, round, and reactive to light and accommodation; client is
agitated and moves all extremities spontaneously but does not follow commands
Integumentary, Superficial lacerations to the face; diffuse bruising noted on upper extremities and chest wall
Pulmonary,
Vital signs: RR 30, SpOz 92% via nonrebreather mask; unilateral chest wall expansion observed on inspiration;
left-sided tracheal deviation noted; breath sounds diminished throughout the right lung field
Cardiovascular,
Vital signs: P 104, BP 90/58; S1 and S2 heard on auscultation; all pulses palpable; no extremity peripheral edema
noted
Psychosocial ,Alcohol odor noted on the client's breath
Drag words from the choices below to fill in the blank/blanks.The nurse understands that the client is most at risk for------------and------------
- A. Sepsis
- B. Delirium tremens
- C. Respiratory failure
- D. Deep venous thrombosis
- E. Decreased cardiac output
Correct Answer: E,C
Rationale: The nurse understands that the client is most at risk for respiratory failure and decreased cardiac output.
Decreased cardiac output is the most concerning complication in a client with a tension pneumothorax. The trapped air in a tension
pneumothorax causes increased pressure, compressing the affected lung more until it is completely collapsed and then compressing the
heart and great vessels (vena cava, aorta), ultimately inhibiting venous return.
If the pleural pressure continues to increase, eventually the pleural cavity will crowd the trachea, forcing it to deviate (shift) to the unaffected
side where the unaffected lung can be compressed. Clients are at high risk for respiratory failure due to hypoxemia. Without treatment, the
lungs cannot meet the demands for oxygenation and the client will die.
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
For each finding below, click to specify if the finding is consistent with the disease process of acute upper gastrointestinal bleed or acute lower gastrointestinal bleed. Each finding may support more than one disease process.
- A. Melena
- B. NSAID use
- C. Hematemesis
- D. History of diverticulosis
- E. History of Helicobacter pylori infection
Correct Answer:
Rationale: Upper gastrointestinal (Gl) bleeding can occur in the esophagus (eg, esophageal varices or in the stomach and duodenum
(eg, peptic ulcer). Findings associated with upper GI bleeding include the following:
• Melena (ie, dark, tarry stools) is due to the release of iron (heme) as blood passes through the entire GI tract and
hemoglobin becomes partially digested
• NSAID use increases the risk of peptic ulcer formation by inhibiting cyclooxygenase-1, an enzyme that helps protect the
stomach lining and promote platelet aggregation.
• Hematemesis (ie, vomiting blood) is due to the presence of blood in the upper GI tract (eg, esophagus, stomach,
duodenum); the blood usually has a coffee ground appearance due to digestion by gastric acid
• Helicobacter pylori infection increases gastric secretions, promoting peptic ulcer formation.
Lower Gl bleeding occurs in structures past the duodenum (eg, small and large intestine, rectum, anus) and is commonly
associated with inflammatory (eg, Crohn disease, ulcerative colitis, diverticulosis) or vascular (eg, hemorrhoids) conditions.
Diverticulosis is a condition where diverticula (ie, hollow outpouchings from the intestine) develop, usually in the large
intestine and occasionally in the small intestine. Diverticula weaken the intestinal wall and increase the risk for GI bleeding.
The nurse is caring for a 34-year-old female client in the clinic.
Nurses' Notes
Initial Clinic Visit
The client is receiving a tuberculin skin test. The client works at a long-term care facility and has never been vaccinated for
tuberculosis. Medical history includes Crohn disease, major depression, and a blood transfusion following a motor vehicle collision 5
years ago. The client takes an immunosuppressant, oral contraceptive pills, and a selective serotonin reuptake inhibitor daily.
The client is currently providing housing for a family member who periodically experiences homelessness. The client has a pet dog.
Clinic Visit 2 Days Later
The client returns to the clinic for inspection of the tuberculin skin test injection site. There is a palpable, raised, hardened area around
the injection site that is 16 mm in diameter.
The client reports no cough, fever, fatigue, anorexia, weight loss, or nocturnal diaphoresis. Lung sounds are clear throughout all lobes
on auscultation.
Vital signs are T 98.5 F (36.9 C), P 72, RR 17, BP 118/72, and SpO 98% on room air.
Clinic Visit 6 Months Later
The client reports fatigue; intermittent fevers; decreased appetite; a 6-Ib (2.7-kg) weight loss; and a productive, chronic cough that
began 5 weeks ago. The client has not started the antibiotic regimen for latent tuberculosis.
Diagnostic Results
Chest x-ray
Lungs appear normal. There are no infiltrates, cavitation, or effusions.
The nurse is reinforcing teaching on the plan of care for active tuberculosis. For each of the statements made by the nurse, click to specify
if the statement is appropriate or not appropriate to include in the teaching.
- A. A nurse will need to watch you take your medications
- B. You should notify anyone that has frequently been in close contact with you
- C. Weekly complete blood counts will track whether your antibiotics are effective
- D. Alcohol use while taking these medications can increase your risk for liver damage
Correct Answer:
Rationale: The duration of standard treatment of active tuberculosis (TB) is long, typically over the course of months, which makes it difficult for many
clients to adhere to the medication regimen. Proper client teaching increases medication adherence and helps minimize transmission of the
infection to others
The nurse should reinforce the following teaching:
• Direct observational therapy, which is the process of directly handing the medications to clients and watching them swallow the
medications. This has been shown to increase medication adherence in clients with active TB.
• Notifying close contacts of clients with recent active TB infection to reduce transmission to others. The nurse should teach the client
to reduce contact with family members and keep living spaces well ventilated.
• Alcohol use increases the risk for liver damage while taking antibiotics for active TB (rifampin, isoniazid, pyrazinamide, ethambutol).
Monitoring antibiotic effectiveness with weekly blood counts is not appropriate because antibiotic effectiveness is evaluated with month
sputum tests until there are two consecutive negative results.