Nokea
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.
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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 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 clinical findings require further follow-up? Select all that apply.
- A. Crepitus noted over the right clavicle
- B. Cyanosis of the hands and feet
- C. Heart rate of 165/min while crying
- D. Jitteriness
- E. Moro reflex is decreased in the right extremity
- F. Respirations of 60/min
Correct Answer: A,D,E
Rationale: Crepitus suggests fracture, jitteriness indicates hypoglycemia, and decreased Moro reflex may indicate nerve injury.
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.
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 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
Which finding is the most concerning to the nurse at this time?
- A. Bilateral leg weakness
- B. Difficulty swallowing
- C. Elevated blood pressure
- D. Radiating lower back pain
Correct Answer: B
Rationale: Difficulty swallowing indicates bulbar involvement in Guillain-Barré syndrome, risking aspiration and requiring urgent intervention.