Nokea
The nurse is caring for a 43-year-old client.
Nurses' Notes Vital Signs
Emergency Department
0800: A 43-year-old client comes to the emergency department due to lower back pain and bilateral leg weakness. The client reports that the weakness began 3 days ago in the feet and has gradually worsened. The client sought treatment today after becoming "so weak that I fell while walking" and noticing new hand weakness and difficulty swallowing. Back pain radiates down both legs and is rated as 5 on a scale of 0-10. The client recently recovered from an illness with flu-like symptoms. The client reports a history of hypertension and takes no medications. Assessment of the lower extremities reveals muscle strength of 2/5 and decreased sensation to pinprick. Achilles tendon and patellar reflexes are decreased
For each finding below, click to specify if the finding is consistent with the disease process of Guillain-Barré syndrome, ischemic brain stroke, or lumbar disk herniation.
- A. Radiating back pain
- B. Difficulty swallowing
- C. Recent viral infection
- D. Ascending muscle weakness
Correct Answer: A,B,C,D
Rationale: Radiating pain is typical of disk herniation, swallowing issues occur in GBS and stroke, viral history and ascending weakness are specific to GBS.
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The nurse is caring for a 16-year-old client.
History and Physical Laboratory Results
Body System- Findings
General- The client comes to the emergency department with pain in the upper back, both knees, and the lower legs that is rated as 9 on a scale of 0-10; medical history includes sickle cell disease; the client reports attending an outdoor sports camp for the past 4 days; the client appears restless with frequent position changes and facial grimacing
Neurological- The client is alert and oriented to person, place, and time
Pulmonary- Vital signs: RR 24, SpOz 95% on room air, breath sounds are clear bilaterally Cardiovascular- Vital signs: T 98.4 F (36.9 C), P 120, BP 130/78; S1 and S2 are auscultated with no murmurs, continuous cardiac monitor shows sinus tachycardia
Gastrointestinal- The abdomen is soft and nontender with normal bowel sounds; the client vomited 30 mL of clear liquid
Musculoskeletal- The client has multiple, tender, bony points
Genitourinary- The client voided 50 mL of clear, amber-colored urine
The client is most likely experiencing ....... and is at risk for.......
- A. Osteomyelitis
- B. Rhabdomyolysis
- C. Sickle acute cell pain episode
- D. Sepsis
- E. Ischemic organ damage
- F. Compartment syndrome
Correct Answer: C,E
Rationale: Severe pain and tachycardia suggest a sickle cell pain episode , with risk for ischemic organ damage due to vaso-occlusion.
The nurse is caring for a 40-year-old client.
History Admission:
The client is brought to the psychiatric emergency department by ambulance after being observed walking in the street and shouting at vehicles. The client states that aliens are trying to attack him and that he is now on a mission to find and kill them. The clients mother says that last year he believed that he was being watched by an unidentified government agency and subsequently broke up with his girlfriend, quit his job, and disconnected his phone. The mother has noticed that he no longer seems to care about activities that used to interest him, and last month she discovered that he had moved into the family garden shed with his dog.
On examination, the client is malodorous and disheveled and laughs for no apparent reason. He appears anxious, avoids eye contact, and shows little emotion. His answers are very brief, and he asks if the interview is being secretly recorded. The client's speech is difficult to follow, and he repeatedly says in a monotone voice, "I said I'll find them." He later becomes angry and refuses to sit in a chair for the interview. I'll find them." He later becomes angry and refuses to sit in a chair for the interview.
For each intervention, click to specify if the intervention is appropriate or not appropriate for the care of the client.
- A. Allow the client to listen to music
- B. Use gentle touch to calm the client
- C. Open medication packages in front of the client
- D. Tell the client that you do not believe that the voices are real
- E. Ask the client if he is hearing voices instructing him to self-harm
Correct Answer: A,C,E
Rationale: Music , transparent medication administration , and assessing self-harm risk are appropriate. Touch may escalate agitation, and denying voices dismisses the client’s reality.
The nurse is caring for a 69-year-old client.
Progress Notes Emergency Department
1100: The client is unconscious following a suicide attempt. The paramedics immediately initiate CPR.
1115: The nurse reviews the client's chart and is unable to find documentation of a durable power of attorney for health care.
For each rationale, click to specify if the rationale is applicable or not applicable regarding the need to continue cardiopulmonary resuscitation.
- A. The client is unconscious
- B. The client is under the age of 70
- C. The client's toxicology report reveals no illegal substances
- D. The client does not have a living will documented in the medical record
Correct Answer: A,D
Rationale: Unconsciousness and no living will support continuing CPR unless a DNR exists. Age and toxicology are irrelevant.
The nurse is assisting the registered nurse with caring for a client who is at 36 weeks gestation. History and Physical Vital Signs
General - Client is gravida 2 para 1 at 36 weeks gestation; reports a throbbing headache rated as / on a scale of 0-10, blurred vision, and epigastric pain; client states that she took 1000 mg of acetaminophen 2 hours ago with no relief, medical history includes seasonal allergies and exercise-induced asthma
Neurological -Patellar deep tendon reflexes 2+ bilaterally, clonus absent
Cardiovascular -Heart tones normal; facial edema noted; +2 pitting edema in bilateral upper extremities; +3 pitting edema in bilateral lower extremities
Gastrointestinal -Client reports fetal movement, no contractions noted; soft uterine resting tone on palpation
Genitourinary -Cervical examination: 1 cm dilated, 0% effaced, -3 fetal station, cephalic fetal presentation, amniotic membranes intact; cesarean birth 5 years ago at 40 weeks gestation for breech fetal presentation, resulting in delivery of healthy newborn
The following abnormal laboratory results support the client's preeclampsia diagnosis:
- A. WBC count
- B. Hemoglobin
- C. Serum creatinine
- D. 24-hour urine protein
Correct Answer: D
Rationale: Elevated 24-hour urine protein is a hallmark of preeclampsia, indicating renal involvement.
Which of the following statements by the client indicate that teaching has been effective? Select all that apply.
- A. I plan to take a 20-minute brisk walk twice daily.'
- B. I should bake or broil foods instead of frying them.'
- C. I should eat white bread instead of multigrain bread.'
- D. I will avoid straining when passing a bowel movement.'
- E. I will drink at least 1 L (1000 mL) of fluid daily.'
Correct Answer: A,B,D
Rationale: Exercise , healthy cooking , and avoiding straining prevent diverticulitis recurrence. White bread is less beneficial than high-fiber foods, and 1 L fluid is insufficient.