For each potential prescription, click to specify whether th...

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 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

Which of the following complications are related to liver cirrhosis? Select all that apply.

A. Abdominal ascites
B. Coagulopathies
C. Esophageal varices
D. Hepatic encephalopathy
E. Malnutrition

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

Rationale: Liver cirrhosis leads to portal hypertension and impaired liver function, causing: A) Abdominal ascites due to fluid accumulation from portal hypertension and hypoalbuminemia; B) Coagulopathies from decreased synthesis of clotting factors; C) Esophageal varices from portal hypertension causing collateral vein formation; D) Hepatic encephalopathy from ammonia buildup due to impaired liver detoxification; E) Malnutrition from impaired nutrient metabolism and absorption.

Nurses' Notes
Emergency Department
A newborn is brought to the emergency department due to coughing and difficulty feeding. The client was born at home 6 hours ago via spontaneous vaginal birth. With each attempt to breastfeed, the client coughs, vomits, and "turns blue." The mother did not receive prenatal care. She reports a history of opioid use disorder but reports no opioid use during pregnancy.
Vital signs: T 98.6 F (37 C), P 120, RR 50, and SpO, 95% on room air. Abdominal distension is present. Ballard scoring estimates the client at 37 weeks gestation. Weight and length are consistent with the 25th and 50th percentiles for estimated age, respectively.
1 Hour Later
After attempting a bottle feed with 10 mL of formula, the client has a coughing episode, and there is formula mixed with saliva in the mouth. Coarse breath sounds are noted bilaterally with intercostal retractions. S1 and S2 are present with no murmurs. Neurologic examination shows normal neuromuscular findings.
A nasogastric tube insertion is attempted per prescription by the health care provider, and resistance is met at 10 cm of insertion.

During a diaper change, the client becomes cyanotic with frothy secretions from the mouth and nose. What action should nurse perform first?

A. Activate the rapid response team
B. Initiate rescue breathing with a bag valve mask
C. Perform nasal and oropharyngeal suction
D. Prepare the newborn for intubation

Correct Answer: C

Rationale: Suctioning clears the airway of frothy secretions, addressing the immediate cause of cyanosis. This is the first priority before other interventions.

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
Nurses' Notes
Outpatient Clinic
0930:
Client received radioactive iodine therapy 6 months ago. Client reports absence of heart palpitations and anxiety. No evidence of fine hand tremor.
Client reports weight gain of 10.5 lbs (4.8 kg) within the past 3 months. Client reports feeling more fatigued during the day and requests to speak to the health care provider about feeling depressed.

Following a routine laboratory draw, the nurse suspects that the client is experiencing primary hypothyroidism as evidenced by........... and ........

A. Increased TSH
B. Decreased TSH
C. Increased T3 and T4 levels
D. Decreased T3 and T4 levels

Correct Answer: A,D

Rationale: Primary hypothyroidism is characterized by increased TSH due to the pituitary gland's attempt to stimulate the thyroid and decreased T3 and T4 levels due to reduced thyroid hormone production.

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.

The nurse should prioritize administration of........... to...........

A. Thiamine
B. Naloxone
C. Oral activated charcoal
D. Prevent respiratory failure

Correct Answer: B,D

Rationale: B to D: Naloxone reverses opioid intoxication to prevent respiratory failure. The client's obtundation, shallow breathing, and pinpoint pupils indicate opioid overdose, requiring urgent reversal to restore breathing. Thiamine is for alcohol-related conditions, and charcoal is for recent ingestions, not specified here.