Nokea
The nurse is caring for a 64-year-old client.
History and Physical
Body System, Findings
General ,
The client reports a 24-hour history of blurred vision and redness in the left eye with a left-sided headache.
This evening, the client developed acute, severe pain in the left eye accompanied by occasional nausea and
vomiting. The client reports no use of systemic or topical eye medications. Medical history includes
osteoarthritis and hypercholesterolemia.
Eye, Ear, Nose, and Throat (EENT),
The client wears eyeglasses to correct farsighted vision. Right eye: pupil 2 mm and reactive to light,
conjunctiva clear. Left eye: pupil 4 mm and nonreactive to light with red conjunctiva. Bilateral lens opacity is noted.
Pulmonary,
Vital signs are RR 20 and SpO, 96% on room air. The lungs are clear to auscultation bilaterally.
Cardiovascular,
Vital signs are T 99 F (37.2 C), P 88, and BP 140/82.
Psychosocial,
The client reports a great deal of emotional stress following the recent death of the client's spouse that is accompanied by lack of sleep, poor appetite, and a 7.9-lb (3.6-kg) weight loss within the past month. The client takes diphenhydramine for sleep.
Select 5 findings that require immediate follow-up.
- A. left-sided headache
- B. Bilateral lens opacity
- C. 7.9-Ib (3.6-kg) weight loss within the past month.
- D. blurred vision and redness in the left eye
- E. severe pain in the left eye
- F. red conjunctiva.
- G. Left eye: pupil 4 mm and nonreactive to light
Correct Answer: A,D,E,F,G
Rationale: This client is experiencing signs of acute angle-closure glaucoma (ACG), a medical emergency characterized by a sudden elevation in
intraocular pressure (IOP). The onset of symptoms is typically sudden; however, acute ACG requires rapid intervention to prevent permane
vision loss. Manifestations of acute ACG include:
• Blurry vision
• Unilateral headache
• Sudden, severe eye pain
• Conjunctival redness
• Middilated pupils (4-6 mm) nonreactive to light
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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 is planning care with the registered nurse. For each potential prescription, click to specify if the prescription is expected or unexpected for the initial care of the client.
- A. Continuous cardiac monitoring
- B. Frequent electrolyte monitoring
- C. Continuous regular insulin IV infusion
- D. Hourly finger-stick blood glucose checks
- E. Nebulized albuterol breathing treatments
- F. 5% dextrose in 0.9% sodium chloride IV infusion
Correct Answer:
Rationale: The priority intervention for diabetic ketoacidosis (DKA) is fluid resuscitation to restore fluid volume and increase organ perfusion. Fluid
resuscitation also treats hypovolemic shock and normalizes electrolyte and blood glucose levels via hemodilution. When planning initial care
for a client with DKA, prescriptions that would be expected include:
• Continuous cardiac monitoring due to the risk for dyshythmias caused by potassium imbalances
• Frequent electrolyte monitoring to assess for electrolyte imbalances from rapid fluid and electrolyte shifts that occur with IV fluid and
insulin administration
• Continuous regular insulin IV infusion of a short-acting insulin used to transport blood glucose into the cells to treat hyperglycemia
and stop ketosis (Glucose levels should be lowered slowly because a rapid decrease in glucose can cause cerebral edema.)
• Hourly finger-stick blood glucose to titrate the insulin dose and monitor glucose levels
Unexpected prescriptions for the initial care of a client with DKA include:
• Albuterol, a beta-adrenergic agonist used to prevent/treat bronchospasm that has the additional effect of decreasing serum potassium
levels. Because the client with DKA is already at risk for hypokalemia due to net potassium deficiency, albuterol increases the client's
risk for dysrhythmias.
• 5% dextrose in 0.9% sodium chloride IV infusion, a sugar-containing solution used to increase blood glucose levels, which would
worsen hyperglycemia
History
Labor and Delivery Unit
Admission: The client, gravida 1 para 0, at 16 weeks gestation with a twin pregnancy reports nausea and vomiting for the past
several weeks. The client also reports dry heaving, increasing weakness, light-headedness, and an inability to tolerate
oral intake for the past 24 hours. In addition, the client has had occasional right-sided, shooting pain from the abdomen
to the groin that occurs with sudden position changes. The pain quickly resolves without intervention per the client's
report. She has had no contractions or vaginal bleeding and has felt no fetal movement during this pregnancy. The
client has a history of childhood asthma and is currently taking no asthma medications. The client reports no other
pregnancy complications.
Physical
Prepregnancy,12 Weeks Gestation 16 Weeks Gestation(Prenatal Visit),(Labor and Delivery Admission)
Height ,5 ft 5 in (165.1 cm),5 ft 5 in (165.1 cm)|, 5 ft 5 in (165.1 cm)
Weight, 145 lb (65.8 kg),148 lb (67.1 kg),138 lb (62.6 kg)
BMI, 24.1 kg/m2, 24.6 kg/m2,23.0 kg/m2
Vital Signs
12 Weeks Gestation(Prenatal Visit),16 Weeks Gestation(Labor and Delivery Admission)
T,98.7 F (37.1 C),99.8 F (37.7 C)
P,70,101
RR,14,18
BP,122/78,90/55
SpO2,99% on room air,96% on room air
Laboratory Results
Laboratory Test and Reference Range, 16 Weeks Gestation
Blood Chemistry.
Sodium
136-145 mEq/L
(136-145 mmol/L)|,
136 mEq/L
(136 mmol/L)
Potassium
3.5-5.0 mEq/L
(3.5-5.0 mmol/L),
2.7 mEq/L
(2.7 mmol/L)
TSH
0.3-5.0 uU/mL
(0.3-5.0 mU/L),
0.4 pu/mL
(0.4 mU/L)
Hematology.
Hemoglobin (pregnant)
>11 g/dL
(>110 g/L),
16 g/dL
(160 g/L)
Hematocrit (pregnant)
>33%
(>0.33),
49%
(0.49)
Urinalysis
Specific gravity
1.005-1.030
1.030,
Ketones
Not present,
Present
Giucose
Not present,
Not present
Nitrites
Not present,
Not present
The nurse has reviewed the information from the Laboratory Results. The nurse suspects that the client may have hyperemesis gravidarum. Which of the following findings support this diagnosis? Select a that apply.
- A. Hematocrit level
- B. Potassium level
- C. TSH level
- D. Urine ketones
- E. Urine specific gravity
Correct Answer: A,B,D,E
Rationale: Hyperemesis gravidarum (HG) is characterized by severe, persistent nausea and vomiting during pregnancy and weight loss of 25% of
prepregnancy weight. The exact cause of HG is unknown, but it is believed that pregnancy-related increases in hormone levels (eg, human
chorionic gonadotropin [hCG]) contribute to the condition. Laboratory findings that assist with the diagnosis of HG include:
• Elevated hematocrit level reflects hemoconcentration, which occurs due to dehydration from excessive vomiting and decreased fluid
intake (Option 1).
• Hypokalemia occurs due to excessive loss of potassium via vomiting and/or insufficient intake of potassium (Option 2).
• Ketonuria (ie, the presence of ketones in urine) results from the metabolism of fat for energy due to a lack of nutritional intake (Option
4).
• High urine specific gravity reflects the concentration of urine; concentrated urine may indicate that the client's volume is depleted,
which is common in HG (Option 5).
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.
Complete the following sentence/sentences by choosing from the list of options. The nurse recognizes that the client is most likely experiencing ----------interventions to prevent ---------
- A. Pleural effusion
- B. Systemic emboli
- C. Cardiac tamponade
- D. pneumonia
- E. pericarditis
- F. Infective endocarditis
Correct Answer: F,B
Rationale: The nurse recognizes that the client is most likely experiencing infective endocarditis (lE) and should prioritize interventions
to prevent systemic emboli.
The client is most likely experiencing IE based on the history of a recent dental procedure and clinical findings of infection (eg,
fever, flu-like symptoms), microemboli (eg, splinter hemorrhages, Janeway lesions), and cardiac murmur. In addition to
microemboli, larger pieces of vegetation can break off the heart valve and embolize to various organs, causing life-threatening
complications (eg, stroke, spleen/kidney infarction).
The nurse is performing a home health visit for an 84-year-old male.
History and Physical
Body System, Findings
General,
Client reports a 1-month-long history of fatigue and dyspnea that has worsened; he is unable to lie
flat and sleeps in a chair at night, medical history includes myocardial infarction, chronic heart
failure, chronic obstructive pulmonary disease, hypertension, and type 2 diabetes mellitus; client
was diagnosed with benign prostatic hyperplasia 8 months ago; client is adherent with prescribed
medications; client reports frequent consumption of donuts, hamburgers, steak, and fried chicken;
BMI is 34 kg/m?; client reports 6-Ib (2.7-kg) weight gain in 1 week
Neurological,
Alert and oriented to person, place, time, and situation
Pulmonary,
Vital signs: RR 24, SpOz 88% on room air; labored breathing, crackles in bilateral lung bases; client
expectorates frothy, pink-tinged sputum; client has a 40-year history of smoking 1 pack of cigarettes
per day
Cardiovascular,
Vital signs: T 98.8 F (37.1 C), P 98, BP 113/92; S1, S2, and S3 present; 3+ bilateral lower extremity
edema
Genitourinary, Concentrated yellow urine; client reports increased urinary hesitancy and urgency
Psychosocial,
Client reports being lonely and has depressed mental status
For each finding below, click to specify if the finding is consistent with the disease process of chronic heart failure or chronic obstructive pulmonary disease. Each finding may support more than one disease process.
- A. Fatigue
- B. Dyspnea
- C. S3 heart tone
- D. Rapid weight gain
- E. Pink, frothy sputum
- F. Barrel-shaped chest
Correct Answer:
Rationale: Chronic heart failure (HF) is a progressive condition characterized by impaired ventricular function that leads to decreased
cardiac output and inadequate tissue perfusion as blood backs up into the lungs and systemic circulation. Common clinical
manifestations of HF include:
• Fatigue and dyspne secondary to impaired gas exchange
• An S3 (eg, ventricular gallop) heart tone, characteristic of HF, occurs during early diastole when blood from the atria
enters the ventricle and hits the less compliant (stiff) ventricular wall, creating an audible vibration
• Rapid weight gain (>5 lb/week [2.3 kg/week]) due to fluid volume overload
• Blood-tinged (ie, pink), frothy sputum due to mixing of blood from the ruptured high-pressured pulmonary veins with
transudative (clear alveolar fluid (pulmonary edema)
Chronic obstructive pulmonary disease (COPD) is a progressive, irreversible respiratory tract condition characterized by
chronic airway inflammation, alveolar destruction and enlargement, and/or increased mucus production. Clients with COPD
have the following:
• Fatigue and dyspnea related to impaired gas exchange
• Appearance of a barrel-shaped chest due to the increased anteroposterior-to-transverse diameter ratio from
hyperinflation of the lungs
The nurse is caring for a 68-year-old client in the emergency department.
Nurses' Notes,
Emergency Department
1020:
The client reports shortness of breath, a 2-lb weight gain over the past week, and lower extremity swelling. The client
reports slight chest discomfort during activity that is relieved with rest. Medical history is significant for hypertension.
myocardial infarction, heart failure, coronary artery disease, and chronic stable angina. Current medications include
metoprolol, furosemide, potassium chloride, lisinopril, and aspirin. The client takes all medications as prescribed except
one; he states, "I do not take that water pill because I got tired of having to go to the bathroom all the time."
S1 and S2 are present; a prominent S3 is heard. Respirations are labored with inspiratory crackles in the middle and at the
base of the lungs. The abdomen is soft and nontender with normoactive bowel sounds. There is 3+ pitting edema in the
bilateral lower extremities.
Vital Signs,
1020
T ,98.8 F (37.1 C)
P, 60
RR, 24
BP, 168/96
SpO2, 90% on room air
Which of the following prescriptions are indicated for this client? Select all that apply.
- A. 12-lead ECG
- B. Chest x-ray
- C. Current weight
- D. Orthostatic vital signs
- E. Serum electrolyte levels
Correct Answer: A,B,C,E
Rationale: This client's medical history includes hypertension, myocardial infarction, heart failure (HF), coronary artery disease, and chronic stable
angina, which place the client at high risk for several complications. When assisting in planning care for a client with a history of HF who is
experiencing dyspnea and chest discomfort, the nurse should anticipate the following prescriptions:
• A 12-lead ECG to assist in identifying acute dyshythmias and acute coronary syndromes (eg, myocardial infarction, unstable angina)
(Option 1)
• Chest x-ray to visualize pulmonary congestion, cardiomegaly, and the presence of other potential causes for the client's dyspnea (eg,
pneumonia, pleural effusion). Common causes of pleural effusions include HF (Option 2).
• The client's current weight to establish a baseline indicator of fluid volume status (Option 3)
• Serum electrolyte levels to identify fluid and electrolyte imbalances that may impair myocardial contractility (Option 5)