For each intervention, click to specify if the intervention...

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.
1000:
The client reports difficulty raising the arms and inability to squeeze the
fingers. The client reports chest tightness and difficulty breathing.

For each intervention, click to specify if the intervention is appropriate or inappropriate for the care of the client.

A. Ensure bedside suction is set up
B. Place a bag valve mask at the bedside
C. Ensure intubation equipment is available
D. Reposition the client in the bed every 2 hours
E. Place the client on continuous cardiac monitoring
F. Apply a sequential compression device to the legs
G. Mark the appropriate surgical site for a tracheotomy

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

Rationale: Suction , bag valve mask , intubation equipment , repositioning , cardiac monitoring , and compression devices prepare for GBS complications. Tracheotomy marking is premature.

The nurse is caring for a 12-year-old client.
History and Physical Vital Signs Body System Findings
General- The client has a 2-day history of decreased appetite, nausea, fatigue, and headaches, the client had a "sore throat" 2 weeks ago that resolved without treatment; BMl is in the 65th percentile
Eye, Ears, Nose, and Throat (EENT)- Periorbital edema; no changes in vision
Pulmonary- Lung sounds clear bilaterally; no increased work of breathing; no cough Cardiovascular- S1 and S2 heard on auscultation; no murmur auscultated; 3+ bilateral lower extremity edema is noted
Gastrointestinal- Bowel sounds present, no masses or tenderness felt Musculoskeletal No joint pain or swelling
Genitourinary- Decreased urination; dark, cola-colored urine

Which of the following choices would be appropriate for the client's dietary needs? Select all that apply.

A. Chicken nuggets, ketchup, and carrot sticks
B. Grilled ham and cheese sandwich with pretzels
C. Plain yogurt with oats, honey, and blueberries
D. Slice of pepperoni pizza with a side salad
E. Wheat toast with unsalted peanut butter and banana

Correct Answer: C,E

Rationale: Low-sodium, low-protein options like yogurt with oats and toast with peanut butter are suitable for glomerulonephritis.

The client is diagnosed with acute postinfectious glomerulonephritis. The client is most at risk for. and

A. Pyelonephritis
B. Cerebral edema
C. Pulmonary edema
D. Hemorrhagic cystitis

Correct Answer: B,C

Rationale: Glomerulonephritis increases risks for cerebral and pulmonary edema due to fluid overload.

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

A. Administer corticosteroids
B. Initiate seizure precautions
C. Administer an oral stool softener
D. Perform intermittent urinary catheterization
E. Perform frequent neuromuscular evaluations
F. Prepare client for surgical spinal cord decompression

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

Rationale: Corticosteroids , stool softeners , catheterization , neuromuscular checks , and surgery are expected for spinal cord compression. Seizure precautions are not routine.

The newborn nurse is attending births in the labor and delivery unit.
Nurses' Notes
Labor and Delivery Unit
0000: A 39-year-old client, gravida 4 para 3, at 38 weeks gestation arrives at the labor and delivery unit reporting contractions every 2-3 min. During this pregnancy, the client was diagnosed with gestational diabetes mellitus and prescribed insulin, but she reports not taking the insulin. The client reports cigarette smoking (3-5 cigarettes/day) but denies alcohol or recreational drug use. The client received treatment for bacterial vaginosis during the second trimester. The client has gained 55 lb (25 kg) during the pregnancy. Group B Streptococcus result is negative. 1400: The newborn is delivered via forceps-assisted vaginal birth at
1400. The newborn was immediately placed in skin-to-skin contact with the mother, dried, and stimulated. Apgar scores are 7 at 1 minute and 9 at 5 minutes
1405: Newborn vital signs are T 97.3 F (36.3 C), P 156, and RR 52.
1415: Newborn weight is obtained. The newborn is 9 lb 15 oz (4500 g). The maternal client is assisted to latch the newborn onto the breast.
1430: Slight bruising to the scalp is noted where forceps were applied. Newborn vital signs are T 97.2 F (36.2 C), P 160, RR 55, and SpO 95% on room air.

Which of the following findings indicate that the newborn's condition has declined? Select all that apply.

A. Axillary temperature is 96.3 F (35.7 C) and respirations are 84/min
B. Blood glucose level is 32 mg/dL (1.8 mmol/L) prior to feeding
C. Newborn is jittery and has a high-pitched cry
D. Newborn is turning toward the breast while in skin-to-skin contact with the mother
E. One wet diaper and no stools are noted since birth

Correct Answer: A,B,C

Rationale: Hypothermia , hypoglycemia , and jitteriness indicate decline, requiring intervention.

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

Click to highlight below the 4 findings that require immediate follow-up.

A. 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
B. The client appears restless with frequent position changes and facial grimacing
C. Vital signs: RR 24, SpO2 95% on room air; breath sounds are clear bilaterally
D. 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
E. The client vomited 30 mL of clear liquid
F. The client has multiple, tender, bony points
G. The client voided 50 mL of clear, amber-colored urine

Correct Answer: A,B,D,F

Rationale: Severe pain , distress signs , tachycardia , and bony tenderness indicate a sickle cell crisis, requiring urgent management.