Nokea
The nurse is caring for a 68-year-old client in the emergency department.
History Physical Vital Signs
Admission: The client comes to the emergency department with progressively worsening back pain that began 3 weeks ago. The pain has become significantly worse over the past 12 hours. Pain level is rated as 8 on a scale of 0-10. The client was recently diagnosed with prostate cancer and has had a poor response to treatment. This morning, the client had trouble walking and reports decreased sensation in the feet. The client also reports mild nausea, difficulty urinating, decreased urinary sensation, and no bowel movement in the past 3 days
For each finding, click to specify whether the finding indicates that the client's condition has improved or not improved.
- A. Muscle strength is rated 4/5
- B. Deep tendon reflexes are rated 2+
- C. Client is experiencing constipation
- D. The client rates pain as 4 on a scale of 0 to 10
- E. Reports feeling sensation with touch to the lower extremities
- F. Bladder scan immediately after voiding indicates residual urine
Correct Answer: A,B,E
Rationale: Improved strength , normal reflexes , and sensation indicate recovery. Constipation , pain , and residual urine suggest ongoing issues.
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The nurse is caring for a 63-year-old client.
Progress Notes
Emergency department
1 week ago: The client is admitted to the hospital with dyspnea, orthopnea, and bilateral leg swelling. The client has hypertension, heart failure, and chronic kidney disease. Medications include furosemide, hydrochlorothiazide, lisinopril, and metoprolol.
Clinic visit
Today: The client was recently discharged from the hospital after treatment for acute heart failure. Symptoms improved after treatment with diuretics. Today, the client reports new-onset muffled hearing and difficulty understanding speech. Examination shows bilateral hearing loss.
Which medication should the nurse clarify with the health care provider?
- A. Furosemide
- B. Hydrochlorothiazide
- C. Lisinopril
- D. Metoprolol
Correct Answer: A
Rationale: Furosemide is associated with ototoxicity, which may cause hearing loss, requiring clarification.
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
For each potential intervention, click to specify if the intervention is indicated or not indicated for the care the client.
- A. Cleanse the client's body thoroughly
- B. Remove the client's abdominal staples
- C. Remove identifying name tags from the client
- D. Notify the organ and tissue donation organization
- E. Allow the family to be present during postmortem care
- F. Remove the drains, urinary catheter, and peripheral IV catheters
Correct Answer: A,C,D,E,F
Rationale: Cleansing the body , removing identifiers , notifying donation organizations , allowing family presence , and removing invasive devices are standard postmortem care. Staples should remain for autopsy or funeral preparation.
The nurse is caring for a 21-year-old client.
Nurses' Notes History and Physical Vital Signs
Emergency Department
0800: The client comes to the emergency department due to fear of having a heart attack. The client reports, "I was taking the bus home from work when my chest started feeling really tight. I'm lucky my friend was there and able to help me get to the hospital. What if my friend is not there next time?" The client describes experiencing similar episodes recently at random places and times and worries about when or where the next attack will occur
Which of the following statements by the nurse are appropriate to include in the teaching? Select all that apply
- A. Avoid driving after taking alprazolam.'
- B. Contact your health care provider immediately if you experience suicidal thoughts.'
- C. Do not abruptly stop taking alprazolam because you may experience withdrawal symptoms.'
- D. Limit alcoholic beverages to no more than one drink a day while taking alprazolam.'
- E. Take sertraline at the onset of a panic attack.'
Correct Answer: A,B,C
Rationale: Alprazolam requires avoiding driving , monitoring for suicidal thoughts , and gradual tapering . Alcohol limits are stricter, and sertraline is not for acute attacks.
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.
The nurse is contacting a client at 28 weeks gestation to review laboratory results and schedule a follow-up prenatal visit. Laboratory Results Laboratory Test and Reference Range 12 Weeks Gestation 26 Weeks Gestation 28 Weeks Gestation
WBC (prostent) 5,000-1多份 (5.0-15.0 × 10°/L) 8,900/mm3 (8.9 × 10°/L) 16,500 /mm° (16.5 × 10%/L)
Hemoglobin (pregnant) 11-16 g/dL (110-160 g/L) 13 g/dL (130 g/L) 10.8 g/dL (108 g/L) Hematocrit (pregnant) 33%-47% (0.33-0.47) 39% (0.39) 32% (0.32)
Chlamydia Negative Positive Negative Hemoglobin A1c 4.0%-5.9% 5.1%
1-hour oral glucose challenge test <140 mg/dL (7.8 mmol/L) 175 mg/dL (9.7 mmol/L)
3-hour oral glucose tolerance test Fasting: <110 mg/dL (6.1 mmol/L) 1 hour: <180 mg/dL (10.0 mmol/L) 2 hour: <140 mg/dL (7.8 mmol/L 3 hour: <70-115 mg/dL (<6.4 mmol/L) Fasting: 115 mg/dL (6.4 mmol/L) 1 hour: 205 mg/dL (11.4 mmol/L) 2 hour: 162 mg/dL (9.0 mg/dL) 3 hour: 135 mg/dL (7.5 mg/dL)
Which 3 instructions should the nurse include in the teaching?
- A. Avoid including carbohydrates in the diet
- B. Draw up NPH insulin into a syringe first and then lispro insulin in the same syringe
- C. Eat a meal 60 minutes after taking the morning insulin dose
- D. Inject insulin into the subcutaneous tissue in the abdomen
- E. Monitor for symptoms such as headache, trembling, hunger, or sweating
- F. Perform fetal kick counts daily to monitor the well-being of the fetus
Correct Answer: D,E,F
Rationale: Abdominal injection , monitoring hypoglycemia symptoms , and fetal kick counts are key for gestational diabetes management.