Following a routine laboratory draw, the nurse suspects that...

The nurse is caring for a 25-year-old female client.
History and Physical
Body System
General
Client reports jitteriness, anxiety, and palpitations for the past 2 months. Fine hand tremor is noted. Client reports insomnia for approximately 1 week.
Integumentary
Client is diaphoretic.
Eye, Ear, Nose, andThroat (EENT)
Exophthalmos is noted. Goiter is present.
Gastrointestinal
Client reports 10 lb (4.5 kg) weight loss over the past month. Bowel sounds are normoactive. Client reports diarrhea for the past few days.
Reproductive
Last menstrual period was 3 months ago.
Vital Signs
T 99.2 F (37.3 C)
P 164
RR 22
BP 156/92
Nurses' Notes
Outpatient Clinic
0930:
Client received radioactive iodine therapy 6 months ago. Client reports absence of heart palpitations and anxiety. No evidence of fine hand tremor.
Client reports weight gain of 10.5 lbs (4.8 kg) within the past 3 months. Client reports feeling more fatigued during the day and requests to speak to the health care provider about feeling depressed.

Following a routine laboratory draw, the nurse suspects that the client is experiencing primary hypothyroidism as evidenced by........... and ........

A. Increased TSH
B. Decreased TSH
C. Increased T3 and T4 levels
D. Decreased T3 and T4 levels

Correct Answer: A,D

Rationale: Primary hypothyroidism is characterized by increased TSH due to the pituitary gland's attempt to stimulate the thyroid and decreased T3 and T4 levels due to reduced thyroid hormone production.

The nurse is caring for a client on the medical-surgical unit.
History
Admission
0500: The client is admitted with an abscess and cellulitis of the right leg. The abscess is noted on the lateral aspect of the right calf, with redness, swelling, and warmth extending from the knee to the ankle. The abscess was incised in the emergency department, and a moderate amount of purulent, yellowish-green drainage was noted. The leg was wrapped with gauze, and the client received the first dose of IV antibiotics and opioids for pain control.
The client reports chronic lower back pain and gastrosophageal reflux disease, and he was admitted to the hospital once last year for gastrointestinal bleeding. He is currently prescribed daily pantoprazole but takes it only a few times a week.
Vital signs: T 100.9 F (38.3 C), P 82, RR 14, BP 130/80, SpO, 95% on room air

Progress Notes
Medical-Surgical Unit
2300:
The client reports nausea, headache, and insomnia. The client is trembling, diaphoretic, and restless.
The client states, "I would sleep better if those mice and cats would stop climbing up and down the walls."
The upper portion of the clients dressing is saturated with yellowish-green drainage. The peripheral V was removed by the client, and dried blood is noted at the IV site. The IV catheter is on the floor. The client yelled and pushed the nurse's hands away during inspection of the IV site.
Vital signs: T 99 F (37.2 C), P 102, RR 18, BP 170/96, SpO≥ 95% on room air

Based on the client's clinical manifestations, which condition should the nurse suspect?

A. Alcohol withdrawal syndrome
B. Gastrointestinal bleeding
C. Opioid withdrawal
D. Sepsis

Correct Answer: A

Rationale: Trembling, diaphoresis, restlessness, hallucinations, and elevated vital signs (P 102, BP 170/96) are classic signs of alcohol withdrawal syndrome, especially given the absence of gastrointestinal bleeding symptoms and the presence of neurological symptoms.

The nurse is caring for a 52-year-old client on the orthopedic unit.
Nurses' Notes
Postoperative Day 1
0900:
The client's left leg was placed in balanced suspension skeletal traction for a fractured femur 12 hours ago. The client is positioned supine in the center of the bed with the foot of the bed elevated 15 degrees. Traction ropes are free of frays, centered in the pulleys, and moving freely with attached weights resting on the bed frame.
Serous drainage noted around the pin sites. Left foot slightly cool to the touch with posterior tibial and dorsalis pedis pulses palpable at 2+ and capillary refill <2 seconds in the toes. Client has normal sensation and movement of the left toes. Client rates left leg pain as 8 on a scale of 0-10.
Vital signs are T 100.4 F (38 C), P 110, RR 18, and BP 132/68. Weight is 173 lb (78.5 kg).

The nurse recognizes that improperly maintained skeletal traction may lead to........ and.....

A. Rheumatoid arthritis
B. Osteomalacia
C. Increased pain
D. Bone malunion
E. Muscle spasms

Correct Answer: C,D

Rationale: Improperly maintained traction can cause increased pain (C) and bone malunion (D) due to misalignment or inadequate stabilization.

The nurse in an inpatient mental health unit is caring for a 43-year-old client.
History
Admission:
The client comes to the inpatient psychiatric facility for an evaluation. The client is having distressing nightmares, flashbacks, and feelings of being "on edge" since a severe motor vehicle collision 6 months ago that resulted in the death of the client's sibling. The client blames self for the sibling's death and verbalizes feelings of guilt. The client reports an inability to sleep well and being quick to anger, both of which led to job loss and the client seeking help. The client reports a loss of interest in previously enjoyed activities, such as working out and interacting with friends. The client has started smoking cigarettes daily since the collision and typically consumes ≥4 alcoholic beverages per day. Mental status examination reveals an irritable, guarded, and easily distracted mood. The client's appearance is well- kept, and grooming and hygiene are appropriate. The client’s speech is hyperverbal yet coherent, and thought process is organized. The client admits to feelings of hopelessness after the death of the sibling. The client reports occasionally seeing "shadows" but no visual hallucinations. The client has no homicidal ideations or history of violence toward others.
Vital signs: P 78, RR 17, BP 132/78.

The nurse suspects that the client is experiencing posttraumatic stress disorder. Which of the following symptoms are consistent with this condition? Select all that apply.

A. Euphoric mood
B. Flashbacks
C. Hypervigilance
D. Irritability
E. Nightmares
F. Self-blame

Correct Answer: B,C,D,E,F

Rationale: Posttraumatic stress disorder (PTSD) is characterized by symptoms such as flashbacks, hypervigilance, irritability, nightmares, and self-blame following a traumatic event. Euphoric mood is not associated with PTSD.

The nurse is caring for a 58-year-old client on a medical-surgical unit.
History and Physical
General
The client is vomiting bright red blood; medical history includes alcohol use disorder, liver cirrhosis, and hypertension; the client was admitted a year ago for alcohol-induced acute pancreatitis

Neurological
The client is oriented to person and place; the pupils are equal, round, and reactive to light and accommodation

Eye, Ear, Nose, and Throat (EENT)
Yellow scleras are noted

Pulmonary
Vital signs are RR 18, SpO 94% on room air

Cardiovascular
Vital signs are T 99 F (37.2 C), P 102, BP 90/40; S1 and S2 are heard on auscultation; peripheral pulses are 2+ in all extremities; 1+ edema is noted at the bilateral lower extremities

Gastrointestinal
The abdomen is distended and nontender to palpation; the flanks are dull to percussion; bowel sounds are hypoactive; distended veins are present around the umbilicus

Genitourinary
Client is voiding amber-colored urine

Complete the following sentence by choosing from the lists of options. The nurse should prioritize interventions for ___ due to the risk of ___.

A. Abdominal ascites
B. Esophageal Varices
C. Hepatic encephalopathy
D. Coma
E. Hypovolemia
F. Spontaneous bacterial peritonitis

Correct Answer: B,E

Rationale: The client is vomiting bright red blood and has low BP (90/40) and elevated pulse (102), indicating hypovolemia (E) from bleeding esophageal varices (B), which is confirmed later. Prioritizing interventions for esophageal varices addresses the bleeding source, and hypovolemia addresses the life-threatening volume loss.

For each potential prescription, click to specify if the prescription is expected or not expected for the care of the client.

A. Restrict fluid intake
B. Offer a low-fiber diet
C. Use incentive spirometer
D. Administer stool softener
E. Administer anticoagulant

Correct Answer: C,D,E

Rationale: Expected prescriptions include using an incentive spirometer (C) to prevent atelectasis, administering a stool softener (D) for constipation, and an anticoagulant (E) for DVT prevention. Fluid restriction (A) and low-fiber diet (B) are not indicated.