For each potential finding below, click to specify if the fi...

The nurse is caring for a 20-year-old female client.
Nurses' Notes
Urgent Care Clinic
0845: The parent brought the client to the clinic due to vomiting and weakness. The parent states that the client has experienced
sore throat and nasal congestion for the past week. The client has had 4 episodes of emesis during the past 24 hours and
diffuse, constant abdominal pain. The parent also reports that the client has had increased thirst and urine output over the
past 2 months.
The client's last menstrual period ended approximately 6 weeks ago with no abnormalities. Pregnancy status is unknown. The
client does not take any medications and does not use tobacco, alcohol, or recreational substances. Family history includes
hypertension and diabetes mellitus.
The client appears drowsy and is oriented to person and time only. The abdomen is soft without rigidity or rebound
tenderness, and bowel sounds are normal. No blood is present in emesis. Respirations are rapid and deep. Breath sounds
are clear.
Vital signs are T 98.8 F (37.1 C), P 128, RR 30, and BP 88/60 mm Hg.
Finger-stick blood glucose level is 600 mg/dL (33.3 mmol/L).

For each potential finding below, click to specify if the finding is consistent with the disease process of diabetic ketoacidosis, ruptured appendix, or ruptured ectopic pregnancy. Each finding may support more than one disease process.

A. Polyuria
B. Vomiting
C. Tachypnea
D. Tachycardia
E. Hyperglycemia
F. Abdominal pain

Correct Answer:

Rationale: Diabetic ketoacidosis (DKA) is a complication of diabetes mellitus that results from lack of insulin. Insulin is required to transport glucose
into cells for energy, which means that lack of insulin leads to intracellular starvation despite the high level of glucose circulating in the blood
(hyperglycemia). Physiologic responses to hyperglycemia include osmotic diuresis (polyuria) for reduction of blood glucose levels and
breakdown of fat into acidic ketone bodies for energy. This leads to states of dehydration (as evidenced by tachycardia), electrolyte
imbalance, and metabolic acidosis. Ketoacidosis leads to tachypnea and deep respirations (Kussmaul respirations), as well as abdominal
pain and vomiting.
Appendicitis is an inflammation of the appendix often resulting from obstruction by fecal matter. Appendiceal obstruction traps colonic fluid
and mucus, causing increased intraluminal pressure and inflammation. This impairs perfusion of the appendix, resulting in swelling and
ischemia. Clinical manifestations include fever, abdominal pain, rebound abdominal tenderness, tachycardia, nausea, and vomiting.
Abdominal pain usually begins near the umbilicus and migrates to the right lower quadrant (eg, McBurney point). Tachypnea, as well as a
compensatory response, can be present, especially if there is a ruptured appendix or evidence of sepsis causing lactic acidosis (metabolic
acidosis).

The nurse is caring for a 37-year-old client.
Admission Note

Antepartum Unit
1100:
The client, gravida 2 para 1 at 34 weeks gestation, is admitted to the hospital with right upper quadrant pain. The client
reports feeling extremely fatigued and nauseated and has vomited 3 times in the past 2 hours.
Physical examination shows right upper quadrant tenderness. Lower extremities have 2+ pitting edema; deep tendon
reflexes are 3+.

Laboratory Results
Laboratory Test and Reference Range, Admission
Hematology.
Platelets
150,000-400,000/mm3
(150-400 x 10°/L),
82,000/mm3
(82 x 10%/L)
Hemoglobin (pregnant)
>11 g/dL
(>110 g/L),
9.6 g/dL
(96 g/L)
Blood Chemistry.
Creatinine
Female: 0.5-1.1 mg/dL
(44.2-97.2 umol/L),
1.5 mg/dL
(114.4 umol/L)
Alanine aminotransferase
4-36 U/L
(0.07-0.60 ukat/L),
265 U/LI
(4.43 pkat/L)
Aspartate aminotransferase
0-35 U/LI
(0-0.58 ukat/L),
308 U/L
(5.14 ukat/L)
Lipase
0-160 U/L,
53 U/L
Amylase
30-220 U/L,
75 U/L
Urine Dipstick
Protein,
Increased

Vital Signs
1100
T,98.6 F (37 C)
P, 112
RR,20
BP,150/80
SpO2.98% on room air

The nurse is reviewing the collected client data to assist with preparing the client's plan of care. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the
nurse should take to address the condition, and 2 parameters the nurse should monitor to measure the client's progress.

A. Administer magnesium sulfate, Encourage small, frequent meals, Administer morphine, Prepare the client for birth, Administer a proton pump inhibitor
B. Pancreatitis, HELLP syndrome, Hyperemesis gravidarum, Gastroesophageal reflux disease
C. Lipase level, Urine ketones, Parameters to Monitor, Clotting factors, Postprandial pain , Deep tendon reflexes

Correct Answer:

Rationale: HELLP (Hemolysis, Elevated Liver enzymes, and Low Platelet count) syndrome is a life-threatening pregnancy-related disorder that typically
occurs >20 weeks gestation. Although HELLP syndrome is often considered a variant of preeclampsia, clients can develop this syndrome
without hypertension or proteinuria. Clinical manifestations may include elevated liver enzymes, right upper quadrant pain (due to swelling of
the liver), malaise, nausea, and decreased platelet count.
Appropriate interventions include:
• Preparing the client for birth, which is the only definitive treatment
• Assisting with the initiation of magnesium sulfate infusion for seizure prophylaxis
• Administering antihypertensive medications PRN to help prevent stroke
• Evaluating deep tendon reflexes frequently to monitor for hyperreflexia and clonus, which may indicate increased central nervous
system irritability and precede eclampsia; hyporeflexia may indicate magnesium toxicity.
• Monitoring clotting factors to evaluate bleeding risk and monitor for disseminated intravascular coagulation, a complication of HELLP
syndrome

Nurses' Notes
Initial Clinic Visit
1100:
The client has experienced enuresis at night for the past 2 weeks and frequently requests to use the
bathroom while at school. The client was previously toilet trained with no nighttime bed wetting for 6 months;
the client recently relocated to a new home and school where the client lives with parents.
The parent reports that the client has recently demonstrated fatigue, irritability, and multiple behavioral
outbursts that resemble past temper tantrums. The client frequently reports feeling thirsty. No dysuria or
urinary hesitancy is reported.
Weight and height were in the 40th percentiles at the previous visit a year ago. Growth charts today show
the client's weight in the 20th percentile and height in the 40th percentile.
The client appears tired and irritable. Dry mucous membranes are noted with no increased work of
breathing. The lungs are clear to auscultation bilaterally. No cardiac murmur is heard.

Select below the 6 findings that require follow-up.

A. enuresis at night
B. recently relocated to a new home and school
C. fatigue, irritability, and multiple
behavioral outbursts
D. frequently reports feeling
thirsty
E. weight in the 20th percentile
F. Dry mucous membranes
G. frequently requests to use
the bathroom while at school

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

Rationale: The nurse should follow up on the following findings:
irritability may manifest as behavioral outbursts.
• Frequent urination and nocturnal enuresis: Frequent urination and involuntary voiding in a child who was previously
toilet trained for at least 6 months indicate excessive urination (ie, polyuria), which is a characteristic finding of multiple
medical conditions (eg, diabetes mellitus [DM], diabetes insipidus).
• Increased thirst and dry mucous membranes: Increased thirst (ie, polydipsia) and dry mucous membranes are signs
of dehydration. Dehydration in the presence of polyuria and weight loss is concerning for DM.
• Weight loss: Weight loss is a common finding in clients with DM because the body is unable to use glucose and instead
breaks down protein and fat stores for energy.
• Fatigue, irritability, and multiple behavioral outbursts: Fatigue and irritability in a client with polydipsia and polyuria
may indicate an energy deficit from altered glucose metabolism related to DM. In a 6-year-old client, fatigue and

History and Physical
Body System
Findings
General
Client reports a 1-week history of general malaise, fever and chills, night sweats, fatigue, and
poor appetite. Client has poorly controlled hypertension, hypercholesterolemia, and mitral
valve prolapse and regurgitation.
Eye, Ear, Nose, and
Throat (EENT)
Poor dental hygiene. Client reports having 2 teeth extracted 3 weeks ago.
Pulmonary
Vital signs are RR 18 and SpO, 96% on room air. Lungs are clear to auscultation bilaterally.
Cardiovascular
Vital signs are T 100.4 F (38 C), P 105, and BP 140/82. Sinus tachycardia with occasional
premature ventricular contractions on cardiac monitor. S1 and S2 heard on auscultation with
loud systolic murmur at the apex. Peripheral pulses 2+; no edema noted.
Integumentary
Small, erythematous macular lesions on both palms. Thin, brown longitudinal lines on several
nail beds.

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

A. Administer IV antibiotics
B. Prepare client for echocardiography
C. Initiate low-flow supplemental oxygen
D. Gather supplies for pericardiocentesis
E. Place peripherally inserted central catheter (PICC)
F. Collect a blood specimen for culture and sensitivity

Correct Answer:

Rationale: Expected prescriptions for clients with suspected infective endocarditis (IE) include:
• Administering IV antibiotics to kill the infectious pathogen
• Preparing the client for echocardiography to identify valvular dysfunction, chamber enlargement, and vegetations
• Placing a peripherally inserted central catheter for long-term IV antibiotic therapy
• Collecting a blood specimen for culture and sensitivity to identify the infectious pathogen
Initiating low-flow supplemental oxygen is not expected because the client is not exhibiting signs of respiratory distress.
Pericardiocentesis is performed to remove excess fluid from the pericardial cavity and prevent progression to cardiac
tamponade. Pericardial effusions are not commonly expected with IE. Furthermore, this client is not exhibiting signs of
pericardial effusion (eg, muffled heart sounds, substernal pain). Therefore, gathering supplies for pericardiocentesis is not
expected.

The nurse has reviewed the information from the Diagnostic Results and Nurses' Notes. For each finding, click to specify whether the finding indicates that the client's status has not changed or has declined

A. BP 102/70
B. T 100.4 F (38 C)
C. Peripheral pulses 1+
D. Shortness of breath when recumbent
E. Scattered crackles on lung auscultation

Correct Answer:

Rationale: Infective endocarditis (E) requires long-term antibiotic therapy (ie, 4-6 weeks). Fever (eg, T 100.4 F [38 C]) can persist for
several days despite appropriate antibiotic therapy.
In addition to the risk for systemic embolism (eg, stroke), clients with IE are at risk for heart failure if the involved valve
becomes dysfunctional. Decreased capillary oxygen saturation, shortness of breath when recumbent, and scattered
crackles on lung auscultation indicate fluid backup in the lungs. In addition, borderline low blood pressure (compared to
uncontrolled high blood pressure at admission) and decreased peripheral pulses (1+ vs 2+ on admission) indicate decreased
cardiac output and are concerning for heart failure.

The nurse is caring for a 16-year-old client. History and Physical
Body System, Finding
General,
Client is brought to the emergency department due to nausea, vomiting, and abdominal pain that began 24 hr
ago. Client has type 1 diabetes mellitus and usually takes insulin. Parents state that the client was at an
overnight camp for the past 4 days and are unsure of how much insulin the client has been taking.
Neurological,
Client is lethargic but arousable to voice. The pupils are equal, round, and reactive to light and accommodation.
Integumentary,
Mucous membranes are dry, skin turgor is poor.
Pulmonary,
Vital signs are RR 36 and SpOz 95% on room air. Lung sounds are clear to auscultation. Deep respirations and a
fruity odor on the breath are noted.
Cardiovascular,
Vital signs are T 98.4 F (36.9 C), P 110, and BP 98/58. Pulses are 3+ on all extremities, and capillary refill time is
4 sec.
Gastrointestinal Normoactive bowel sounds are heard in all 4 quadrants; the abdomen is nontender.
Genitourinary,
Client voided dark yellow urine.
Endocrine,
Client is prescribed levothyroxine daily for hypothyroidism and has missed one dose of levothyroxine.
Psychosocial,
Parents state that the client has been sad and slightly withdrawn for the past 2 weeks after ending a romantic relationship.
Laboratory Results
Laboratory Test and Reference Range, 1000, 1600
Blood Chemistry.
Glucose (random)
≤200 mg/dL
(≤11.1 mmol/L),
504 mg/dL
(28.0 mmol/L),
164 mg/dL
(9.1 mmol/L)
Sodium
136-145 mEq/L
(136-145 mmol/L),
133 mEq/L
(133 mmol/L),
135 mEq/L
(135 mmol/L)
Chloride
98-106 mEq/L
(98-106 mmol/L),
101 mEq/L
(101 mmol/L),
102 mEq/L
(102 mmol/L)
Potassium
3.5-5.0 mEq/L
(3.5-5.0 mmol/L),
5.6 mEq/L
(5.6 mmol/L),
3.2 mEq/L
(3.2 mmol/L)
Arterial Blood Gases
Arterial pH
7.35-7.45
(7.35-7.45),
7.20
(7.20),
7.31
(7.31)
HCOg
21-28 mEq/L
(21-28 mmol/L),
13 mEq/L
(13 mmol/L),
18 mEq/L
(18 mmol/L)
PaCO,
35-45 mm Hg
(4.66-5.98 kPa),
30 mm Hg
(3.99 KPa),
32 mm Hg
(4.26 kPa)
PaO,
80-100 mm Hg
(10.64-13.33 KPa),
90 mm Hg
(11.97 kPa),
90 mm Hg
(11.97 kPa)

The nurse has reviewed the information from the Laboratory Results., For each client finding below, click to specify if the finding is consistent with the disease process of diabetic ketoacidosis or hyperosmolar hyperglycemic state. Each finding may support more than one disease process.

A. P 110
B. pH 7.2
C. BP 98/58
D. Poor skin turgor
E. Fruity breath odor
F. Positive urine ketones
G. Kussmaul respiration

Correct Answer:

Rationale: Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are potentially life-threatening complications of diabetes mellitus
(DM). Clients with a decreased level of consciousness, hyperglycemia, electrolyte imbalances, and signs of dehydration should be evaluate
for both DKA and HHS.
DKA is more common in type 1 DM caused by hypoinsulinemia, resulting in hyperglycemia, metabolic acidosis (le, low pH), ketosis (le,
positive ketones in the urine and fruity odor on the breath), and severe dehydration (eg, poor skin turgor, tachycardia, hypotension)
due to osmotic water loss caused by glucosuria. Glucose and potassium are unable to enter the cell due to lack of insulin, causing electroly
imbalances. Kussmaul respirations are deep, rapid breaths that compensate for metabolic acidosis by expelling carbon dioxide (le, an acid)
HHS is characterized by high plasma osmolality and extreme hyperglycemia. Osmolality is increased with dehydration. HHS is more
common in type 2 DM due to a small amount of insulin available to prevent ketosis. Therefore, clients with HHS have a near normal pH leve
and minimal to no urine ketones. Osmotic diuresis and polyuria create a significant fluid volume deficit, causing electrolyte imbalances and
dehydration (eg, poor skin turgor, tachycardia, hypotension), which can lead to hypovolemic shock.
Educational objective:

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