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

The nurse in an inpatient mental health unit is caring for a 43-year-old client.
History
Admission:
The client comes to the inpatient psychiatric facility for an evaluation. The client is having distressing nightmares, flashbacks, and feelings of being "on edge" since a severe motor vehicle collision 6 months ago that resulted in the death of the client's sibling. The client blames self for the sibling's death and verbalizes feelings of guilt. The client reports an inability to sleep well and being quick to anger, both of which led to job loss and the client seeking help. The client reports a loss of interest in previously enjoyed activities, such as working out and interacting with friends. The client has started smoking cigarettes daily since the collision and typically consumes ≥4 alcoholic beverages per day. Mental status examination reveals an irritable, guarded, and easily distracted mood. The client's appearance is well- kept, and grooming and hygiene are appropriate. The client’s speech is hyperverbal yet coherent, and thought process is organized. The client admits to feelings of hopelessness after the death of the sibling. The client reports occasionally seeing "shadows" but no visual hallucinations. The client has no homicidal ideations or history of violence toward others.
Vital signs: P 78, RR 17, BP 132/78.

Nurses' Notes
Inpatient - Mental Health Unit
2100:
Client appears anxious and withdrawn, and states, "I am afraid to sleep at night because I get nightmares about my sibling." The client would not elaborate on the content of the nightmares.

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

A. Provide the client privacy during flashbacks
B. Help the client identify available support systems
C. Directly ask if the client is having thoughts of self-harm
D. Determine the client's ability to perform activities of daily living
E. Reinforce the use of progressive muscle relaxation for anxiety
F. Avoid discussion of the traumatic event when speaking to the client

Correct Answer: B,C,E

Rationale: Appropriate interventions include identifying support systems (B), directly assessing for self-harm (C), and using relaxation techniques (E). Providing privacy during flashbacks (A) may increase distress, assessing ADLs (D) is less urgent, and avoiding discussion of the trauma (F) may hinder therapeutic progress.

The nurse is caring for a 58-year-old client on a medical-surgical unit.
History and Physical
General
The client is vomiting bright red blood; medical history includes alcohol use disorder, liver cirrhosis, and hypertension; the client was admitted a year ago for alcohol-induced acute pancreatitis

Neurological
The client is oriented to person and place; the pupils are equal, round, and reactive to light and accommodation

Eye, Ear, Nose, and Throat (EENT)
Yellow scleras are noted

Pulmonary
Vital signs are RR 18, SpO 94% on room air

Cardiovascular
Vital signs are T 99 F (37.2 C), P 102, BP 90/40; S1 and S2 are heard on auscultation; peripheral pulses are 2+ in all extremities; 1+ edema is noted at the bilateral lower extremities

Gastrointestinal
The abdomen is distended and nontender to palpation; the flanks are dull to percussion; bowel sounds are hypoactive; distended veins are present around the umbilicus

Genitourinary
Client is voiding amber-colored urine

Complete the following sentence by choosing from the lists of options. The nurse should prioritize interventions for ___ due to the risk of ___.

A. Abdominal ascites
B. Esophageal Varices
C. Hepatic encephalopathy
D. Coma
E. Hypovolemia
F. Spontaneous bacterial peritonitis

Correct Answer: B,E

Rationale: The client is vomiting bright red blood and has low BP (90/40) and elevated pulse (102), indicating hypovolemia (E) from bleeding esophageal varices (B), which is confirmed later. Prioritizing interventions for esophageal varices addresses the bleeding source, and hypovolemia addresses the life-threatening volume loss.

The nurse is caring for a 25-year-old female client.
History and Physical
Body System
General
Client reports jitteriness, anxiety, and palpitations for the past 2 months. Fine hand tremor is noted. Client reports insomnia for approximately 1 week.
Integumentary
Client is diaphoretic.
Eye, Ear, Nose, andThroat (EENT)
Exophthalmos is noted. Goiter is present.
Gastrointestinal
Client reports 10 lb (4.5 kg) weight loss over the past month. Bowel sounds are normoactive. Client reports diarrhea for the past few days.
Reproductive
Last menstrual period was 3 months ago.
Vital Signs
T 99.2 F (37.3 C)
P 164
RR 22
BP 156/92

For each finding below, click to specify if the finding is consistent with the disease process of hyperthyroidism or hypothyroidism. Each finding may support more than one disease process. Note: Each column must have at least one response option selected.

A. Weight gain
B. Tachycardia
C. Constipation
D. Exophthalmos
E. Heat intolerance
F. Fine hand tremor

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

Rationale: Hyperthyroidism is characterized by increased metabolic rate, leading to tachycardia, exophthalmos, heat intolerance, and fine hand tremor. Hypothyroidism, with a decreased metabolic rate, is associated with weight gain and constipation.

For each potential prescription, click to specify whether the prescription is anticipated or not anticipated at this time.

A. Administer propranolol
B. Administer methimazole
C. Perform a pregnancy test
D. Maintain a high-calorie diet
E. Offer moisturizing eye drops
F. Maintain continuous cardiac monitoring
G. Administer thyroid hormone replacement

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

Rationale: A: Propranolol is anticipated to manage tachycardia and palpitations. B: Methimazole is anticipated to treat hyperthyroidism by reducing thyroid hormone production. C: A pregnancy test is anticipated due to the absence of menstruation for 3 months, as pregnancy can affect treatment choices. D: A high-calorie diet is anticipated to address weight loss and increased metabolism. E: Moisturizing eye drops are anticipated for exophthalmos-related eye dryness. F: Continuous cardiac monitoring is anticipated due to the high pulse rate (164). G: Thyroid hormone replacement is not anticipated, as the client has hyperthyroidism, not hypothyroidism.

The nurse in the surgical unit is caring for a 57-year-old client who underwent an abdominal hysterectomy.
Progress Notes
1 Day Postoperative
0800:
The client underwent total abdominal hysterectomy with bilateral oophorectomy and tumor debulking 1 day ago for treatment of ovarian cancer. She has had four episodes of vomiting with bilious emesis over the past 12 hours, which have continued despite V antiemetic administration. The client has been receiving V broad-spectrum antibiotics since the procedure. The skin is warm. A low transverse abdominal incision is present; staples are clean and dry. Chest expansion is symmetric; respirations are unlabored: diminished breath sounds are auscultated in bilateral lower lobes. Radial pulses 2+ bilaterally, capillary refill <3 seconds in all four extremities; no peripheral edema is noted. The client reports frequent hot flashes occurring roughly every hour, starting last night. The abdomen is markedly distended and tender to palpation. Bowel sounds are absent in all four quadrants; the client reports no flatus. Urine is clear yellow with moderate output. The client reports incontinence with coughing or during episodes of vomiting.

Prescriptions
0820:
• 5% dextrose and 0.45% sodium chloride at 75 m/hr continuous
• 50% dextrose 25 mg IV push as needed for blood glucose <70 mg/dL (3.9 mmol/L)
• Ketorolac 15 mg IV push every 6 hours as needed for severe pain
• Ondansetron 8 mg PO every 8 hours as needed for nausea
• Pantoprazole 40 mg PO daily
• Potassium chloride 40 mEq/100 mL IVPB once
• Sips of clear liquids, advance diet as tolerated

Laboratory Results
Laboratory Test and Reference Range: 1 day postoperative

WBC count:
5000-10.000/mm3 (5-10 × 10%L): 12,000/mm3 (12 × 10°/L)

Urea nitrogen (BUN)
10-20 mg/dL (3.6-7.1 mmol/L): 24 mg/dL (8.6 mmol/L)

Creatinine
Male: 0.6-1.2 mg/dL(53-106 umol/L):
1.6 mg/dL (141.4 pmol/L)
Female: 0.5-1.1 mg/dL (44-97 umol/L):

Potassium
3.5-5.0 mEq/L (3.5--5.0 mmol/L): 3.3 mEq/L (3.3 mmol/L)

Sodium
135-145 mEq/L (135-145 mmol/L): 137 mEq/L (137 mmol/L)

Blood glucose level
74-106 mg/dL (4.1-5.9 mmol/L): 75 mg/dL (4.2 mmol/L)

The nurse has reviewed the information from the Prescriptions and Laboratory Results. The nurse is planning care with the registered nurse. Select 2 prescriptions the nurse should anticipate initiating first.

A. 5% dextrose and 0.45% sodium chloride at 75 m/hr continuous
B. 50% dextrose 25 mg IV push as needed for blood glucose <70 mg/dL (3.9 mmol/L)
C. Ketorolac 15 mg IV push every 6 hours as needed for severe pain
D. Ondansetron 8 mg PO every 8 hours as needed for nausea
E. Pantoprazole 40 mg PO daily
F. Potassium chloride 40 mEq/100 mL IVPB once
G. Sips of clear liquids, advance diet as tolerated

Correct Answer: A, F

Rationale: IV fluids (A) are critical to maintain hydration and electrolyte balance, especially with vomiting and ileus. Potassium chloride (F) addresses the low potassium level (3.3 mEq/L). Dextrose is not needed with normal glucose (75 mg/dL). Ketorolac and ondansetron are as-needed, and pantoprazole is daily but less urgent. Clear liquids may exacerbate ileus.

The nurse in the emergency department is caring for a 62-year-old client.
Progress Notes
Emergency Department
0900: The client is brought to the emergency department by a family member after being found confused and lethargic. On arrival, the client is obtunded and does not respond to verbal stimuli.
Medical history includes major depressive disorder and chronic neck and back pain after a motor vehicle collision 2 years ago. The family member states that the client takes multiple medications but does not know which kind. The client was divorced a few months ago.
Physical examination shows 1-mm pupils, shallow breathing, and reduced bowel sounds. Fingerstick blood glucose is 78 mg/dL (4.3 mmol/L). ECG reveals normal sinus rhythm. Breath alcohol test is negative.
Vital signs: T 98.1 F (36.7 C), P 62, RR 8, BP 80/40, SpO, 94% on room air.

What condition should the nurse suspect?

A. Bacterial meningitis
B. Opioid intoxication
C. Transient ischemic attack
D. Wernicke encephalopathy

Correct Answer: B

Rationale: Opioid intoxication is indicated by pinpoint pupils, shallow breathing, obtundation, and hypotension, consistent with the client's history of chronic pain and positive opioid urine screen. Meningitis typically involves fever and neck stiffness, TIA involves focal neurological deficits, and Wernicke's involves confusion with ocular abnormalities and ataxia.