Nokea
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
For each potential prescription, click to specify if the prescription is anticipated or unanticipated for the care of the client.
- A. Obtain daily weights
- B. Maintain fluid restrictions
- C. Administer loop diuretics
- D. Maintain client on strict bed rest
- E. Administer ibuprofen as needed for headache
Correct Answer: A,B,C
Rationale: Daily weights , fluid restrictions , and diuretics manage fluid overload. Bed rest is unnecessary, and ibuprofen risks renal damage.
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The nurse is assisting the registered nurse with caring for a client who is at 36 weeks gestation. History and Physical Vital Signs
General - Client is gravida 2 para 1 at 36 weeks gestation; reports a throbbing headache rated as / on a scale of 0-10, blurred vision, and epigastric pain; client states that she took 1000 mg of acetaminophen 2 hours ago with no relief, medical history includes seasonal allergies and exercise-induced asthma
Neurological -Patellar deep tendon reflexes 2+ bilaterally, clonus absent
Cardiovascular -Heart tones normal; facial edema noted; +2 pitting edema in bilateral upper extremities; +3 pitting edema in bilateral lower extremities
Gastrointestinal -Client reports fetal movement, no contractions noted; soft uterine resting tone on palpation
Genitourinary -Cervical examination: 1 cm dilated, 0% effaced, -3 fetal station, cephalic fetal presentation, amniotic membranes intact; cesarean birth 5 years ago at 40 weeks gestation for breech fetal presentation, resulting in delivery of healthy newborn
For each potential intervention, click to specify if the intervention is indicated or not indicated for the care the client.
- A. Cleanse the client's body thoroughly
- B. Remove the client's abdominal staples
- C. Remove identifying name tags from the client
- D. Notify the organ and tissue donation organization
- E. Allow the family to be present during postmortem care
- F. Remove the drains, urinary catheter, and peripheral IV catheters
Correct Answer: A,C,D,E,F
Rationale: Cleansing the body , removing identifiers , notifying donation organizations , allowing family presence , and removing invasive devices are standard postmortem care. Staples should remain for autopsy or funeral preparation.
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 finding, click to specify whether the finding indicates that the client's condition has improved or not improved.
- A. Muscle strength is rated 4/5
- B. Deep tendon reflexes are rated 2+
- C. Client is experiencing constipation
- D. The client rates pain as 4 on a scale of 0 to 10
- E. Reports feeling sensation with touch to the lower extremities
- F. Bladder scan immediately after voiding indicates residual urine
Correct Answer: A,B,E
Rationale: Improved strength , normal reflexes , and sensation indicate recovery. Constipation , pain , and residual urine suggest ongoing issues.
The nurse is caring for a 55-year-old client in the clinic.
History and Physical
Body System
Findings: General - The client reports cramping pain in the left calf that has worsened over the past year. The pain is precipitated by walking and is partially relieved with rest. The client reports difficulty walking more than 3 blocks. Height: 72 in (182.9 cm), weight: 250 lb (113.4 kg), BMI: 33.9 kg/m?
Pulmonary- Vital signs are RR 16, SpO, 97% on room air. Client reports smoking 1 pack of cigarettes daily for the past 35 years. Breath sounds are mildly decreased throughout with mild prolonged expiration. Client has a history of chronic obstructive pulmonary disease.
Cardiovascular- Vital signs are T 98.8 F (37.1 C), P 82, BP 146/82. S1 and S2 heard on auscultation. The left lower extremity (LLE) is cooler to touch than the right and appears shiny with sparse hair. LLE pulses: femoral 2+, popliteal 1+, posterior tibia 1+, dorsalis pedis audible with Doppler. LLE capillary refill >3 sec. Client has a history of hypertension.
Gastrointestinal- Client is obese. No tenderness, guarding, masses, bruits, or hepatosplenomegaly.
For each potential finding below, click to specify if the finding is consistent with the disease process of chronic venous insufficiency or peripheral artery disease.
- A. Peripheral edema
- B. Decreased leg hair
- C. Decreased peripheral pulses
- D. Skin temperature cool to touch
- E. Pain improves with leg elevation
Correct Answer: A, B,C,D,E
Rationale: Edema and pain relief with elevation are typical of venous insufficiency. Hair loss , weak pulses , and cool skin indicate arterial insufficiency.
The nurse is caring for a 69-year-old client.
Progress Notes Emergency Department
1100: The client is unconscious following a suicide attempt. The paramedics immediately initiate CPR.
1115: The nurse reviews the client's chart and is unable to find documentation of a durable power of attorney for health care.
For each rationale, click to specify if the rationale is applicable or not applicable regarding the need to continue cardiopulmonary resuscitation.
- A. The client is unconscious
- B. The client is under the age of 70
- C. The client's toxicology report reveals no illegal substances
- D. The client does not have a living will documented in the medical record
Correct Answer: A,D
Rationale: Unconsciousness and no living will support continuing CPR unless a DNR exists. Age and toxicology are irrelevant.
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
Which 3 findings require immediate follow-up?
- A. Cardiovascular findings
- B. Genitourinary symptoms
- C. Musculoskeletal symptoms
- D. Neurologic symptoms
- E. Vital signs
Correct Answer: B,C,D
Rationale: Urinary retention , trouble walking , and decreased sensation suggest spinal cord compression, requiring urgent intervention.