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

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

For each potential intervention, click to specify if the intervention is indicated or contraindicated for the care of the client.

A. Encourage the use of positive self-talk
B. Ask the client about any recent life stressors
C. Assist the client to recognize physical symptoms of anxiety
D. Encourage the client to spend time alone when feeling anxious
E. Reinforce abdominal breathing exercises to use at the onset of anxiety

Correct Answer: A,B,C,E

Rationale: Positive self-talk , identifying stressors , recognizing symptoms , and breathing exercises manage panic disorder. Isolation may worsen anxiety.

The nurse is caring for a 75-year-old female client. Nurses' Notes Laboratory Results Diagnostic Results Emergency Department
The client is transferred to the emergency department from a skilled nursing facility for a 3-day history of left lower quadrant abdominal pain rated 8 on a scale of 0-10, loss of appetite, and nausea. Although the client has a history of chronic constipation, she has had 2 or 3 loose stools daily for 1 week. The client reports tenderness on deep palpation of the left lower quadrant. There is an area of blanchable redness on the coccyx. The stool is positive for occult blood.
The client has residual left-sided weakness from an ischemic stroke 2 years ago and ambulates with a walker. The client reports falling several times in the past 6 months; the last fall was 3 weeks ago No ecchymosis or injuries are noted. The client had a hysterectomy and salpingo-oophorectomy for uterine fibroids 20 years ago. Vital signs are T 100 F (37.8 C), P 98, RR 17, BP 126/68, and SpOz 97% on room air.
Medical-Surgical Unit: 4 Days Later
The client continues to experience left lower quadrant pain, decreased appetite, and nausea. Today, she developed chills. Stool frequency has not increased. Severe tenderness is noted in the left lower quadrant, and a mass is palpable. Vital signs are T 101.3 F (38.5 C), P 112, RR 17, BP 110/80, SpO, 97% on room air.

Click to highlight below the findings that are most concerning at this time.

A. The client is transferred to the emergency department from a skilled nursing facility for a 3-day history of left lower quadrant abdominal pain rated 8 on a scale of 0-10, loss of appetite, and nausea.
B. Although the client has a history of chronic constipation, she has had 2 or 3 loose stools daily for 1 week.
C. The client reports tenderness on deep palpation of the left lower quadrant. There is an area of blanchable redness on the coccyx. The stool is positive for occult blood.
D. The client has residual left-sided weakness from an ischemic stroke 2 years ago and ambulates with a walker.
E. The client reports falling several times in the past 6 months; the last fall was 3 weeks ago. No ecchymosis or injuries are noted.
F. The client had a hysterectomy and salpingo-oophorectomy for uterine fibroids 20 years ago. Vital signs are T 100 F (37.8 C), P 98, RR 17, BP 126/68, and SpO2 97% on room air.

Correct Answer: A,C

Rationale: Severe abdominal pain with nausea and tenderness with occult blood suggest acute diverticulitis, requiring urgent evaluation.

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

The nurse should prioritize interventions for........... to prevent .........

A. Hypercalcemia
B. Spinal cord compressions
C. Syndrome of inappropriate antidiuretic hormone
D. Seizure
E. Paralysis
F. Dysrhythmias

Correct Answer: B,E

Rationale: Spinal cord compression interventions aim to prevent paralysis due to nerve damage.

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 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

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 who is brought to the emergency department due to confusion.
History and Physical Body System Findings
General- Client's adult child reports the confusion started this morning, following 3 days of fever and productive cough; medical history includes small bowel resection 10 days ago, chronic heart failure, and coronary artery disease
Neurological- Client is drowsy and oriented to person only, but intermittently agitated Integumentary- Small abdominal surgical incision is present over lower left quadrant, edges are well approximated, and no redness or drainage is noted
Pulmonary- Vital signs are RR 24 and SpO 90% on room air; labored breathing is observed, and crackles and diminished breath sounds are auscultated over right lower chest; client is expectorating yellow sputum; history includes smoking a pack of cigarettes daily for the past 40 years
Cardiovascular- Vital signs are T 102.9 F (39.4 C), P 110, and BP 110/70; S1 and S2 are heard on auscultation; bilateral lower extremity edema is 1+; ECG shows sinus tachycardia
Gastrointestinal- Normoactive bowel sounds are auscultated; client's last bowel movement was 1 day ago
Genitourinary- Client voided concentrated yellow urine

Click to highlight below the findings that require follow-up by the nurse.

A. 3 days of fever and productive cough
B. crackles and diminished breath sounds are auscultated over right lower chest
C. bilateral lower extremity edema is 1+
D. client's last bowel movement was 1 day ago

Correct Answer: A,B

Rationale: Fever with cough and crackles indicate pneumonia, requiring immediate intervention.