Select below the 5 findings that require follow-up.

History and Physical
Body System,Findings
General
Client has history of coronary artery disease, hypertension, hyperlipidemia, diverticulosis, and
osteoarthritis; Helicobacter pylori infection 2 years ago; client reports taking over-the-counter
ibuprofen every 8 hours for left knee pain for the past 2 weeks; daily medications include aspirin,
carvedilol, lisinopril, and atorvastatin
Neurological
Alert and oriented to person, place, time, and situation
Pulmonary
Vital signs: RR 20, SpO 96% on room air, lung sounds clear bilaterally; no shortness of breath;
client smokes 1 pack of cigarettes per day and smokes marijuana 1 or 2 times weekly
Cardiovascular
Vital signs: P 110, BP 90/62; no chest pain; S1 and S2 heard on auscultation; peripheral pulses
2+; client states feeling lightheaded and reports passing out about 1 hour ago
Gastrointestinal
Abdominal pain rated as 4 on a scale of 0-10; one episode of hematemesis; two episodes of
large, black, liquid stools in the morning
Musculoskeletal
Examination of the knees shows crepitus that is worse on the left; no swelling, warmth, or
erythema; range of motion is normal
Psychosocial
Client reports drinking 1 or 2 glasses of wine per day

A. ibuprofen every 8 hours
B. smokes marijuana 1 or 2 times weekly
C. client states feeling lightheaded and reports passing out about 1 hour ago
D. black, liquid stools
E. crepitus that is worse on the left;
F. Vital signs: P 110, BP 90/62; no chest pain;
G. Abdominal pain rated as 4 on a scale of 0-10; one episode of hematemesis;

Correct Answer: A,C,D,F,G

Rationale: A client with hematemesis and black stools is most likely experiencing an acute gastrointestinal (GI) bleed. GI bleeding is a
life-threatening condition that can lead to hemorrhagic shock without immediate intervention. The nurse should immediately
follow up on:
• Chronic NSAID use (eg, ibuprofen), a common cause of drug-induced upper GI bleeds that must be discontinued.
• Hypotension and tachycardia, manifestations of hypovolemia. Hypotension occurs with decreased cardiac output, and
tachycardia is a compensatory mechanism to promote maximum perfusion to vital organs. Because this client has a
history of hypertension, even borderline low blood pressure is considered abnormal.
• Syncope (ie, passing out), a clinical finding associated with hypovolemia caused by decreased perfusion to the brain.
• Hematemesis (ie, vomiting blood), indicative of bleeding in the upper GI tract (eg, stomach ulcers, esophageal varices).
• Dark/black and/or tarry stools, most often associated with upper GI bleeding; blood becomes partially digested as it
passes through the Gl tract, resulting in the dark color.

The nurse is caring for a 20-year-old female client.
Nurses' Notes
Urgent Care Clinic
0845: The parent brought the client to the clinic due to vomiting and weakness. The parent states that the client has experienced
sore throat and nasal congestion for the past week. The client has had 4 episodes of emesis during the past 24 hours and
diffuse, constant abdominal pain. The parent also reports that the client has had increased thirst and urine output over the
past 2 months.
The client's last menstrual period ended approximately 6 weeks ago with no abnormalities. Pregnancy status is unknown. The
client does not take any medications and does not use tobacco, alcohol, or recreational substances. Family history includes
hypertension and diabetes mellitus.
The client appears drowsy and is oriented to person and time only. The abdomen is soft without rigidity or rebound
tenderness, and bowel sounds are normal. No blood is present in emesis. Respirations are rapid and deep. Breath sounds
are clear.
Vital signs are T 98.8 F (37.1 C), P 128, RR 30, and BP 88/60 mm Hg.
Finger-stick blood glucose level is 600 mg/dL (33.3 mmol/L).

Select 5 findings that require immediate follow-up.

A. sore throat and nasal congestion for the past week
B. Pregnancy status is
unknown.
C. The abdomen is soft without rigidity or
rebound tenderness,
D. appears drowsy and is oriented to person and time on
E. Vital signs are T 98.8 F (37.1 C), V P 128, V RR 30, and BP 88/60 mm Hg
F. Finger-stick blood glucose level is 600 mg/dL (33.3 mmol/L) .

Correct Answer: B,D,E,F

Rationale: This client has findings of chronic hyperglycemia, including polydipsia (increased thirst) and polyuria (increased urination) which may indicate
untreated diabetes mellitus. Recent findings also indicate potential upper respiratory infection, hypovolemia, and an acute abdominal
condition. For this client, the following findings are the priority for follow-up:
• Delayed menstruation (time since last menstruation exceeds typical cycle length) could indicate that the client is pregnant, which
presents a risk for pregnancy-related complications (eg, ruptured ectopic pregnancy) and affects care provided to the client (eg, avoid x-
rays and teratogenic medications).
• Decreased level of consciousness (eg, drowsiness, disorientation) places the client at increased risk for injury and aspiration and
may indicate impaired brain perfusion. This may be due to hypotension or hyperglycemia-induced cerebral edema.
• Hypotension causes impaired organ perfusion that could be life threatening without immediate intervention.
• Tachycardia occurs to compensate for hypotension or can be the cause of hypotension and requires prompt attention to prevent
cardiovascular collapse.
• Tachypnea is concerning, particularly when associated with rapid, deep respirations (ie, Kussmaul breathing), because it may indicate a
compensatory response to an underlying metabolic acidosis (eg, ketoacidosis, hypotension-induced lactic acidosis).
• Severe hyperglycemia may indicate diabetic ketoacidosis (DKA), a life-threatening complication of diabetes mellitus. In addition,
hyperglycemia has a diuretic effect leading to fluid loss that worsens cardiovascular compromise.

The nurse is caring for a 34-year-old female client in the clinic.
Nurses' Notes

Initial Clinic Visit
The client is receiving a tuberculin skin test. The client works at a long-term care facility and has never been vaccinated for
tuberculosis. Medical history includes Crohn disease, major depression, and a blood transfusion following a motor vehicle collision 5
years ago. The client takes an immunosuppressant, oral contraceptive pills, and a selective serotonin reuptake inhibitor daily.
The client is currently providing housing for a family member who periodically experiences homelessness. The client has a pet dog.
Clinic Visit 2 Days Later
The client returns to the clinic for inspection of the tuberculin skin test injection site. There is a palpable, raised, hardened area around
the injection site that is 16 mm in diameter.
The client reports no cough, fever, fatigue, anorexia, weight loss, or nocturnal diaphoresis. Lung sounds are clear throughout all lobes
on auscultation.
Vital signs are T 98.5 F (36.9 C), P 72, RR 17, BP 118/72, and SpO 98% on room air.
Clinic Visit 6 Months Later
The client reports fatigue; intermittent fevers; decreased appetite; a 6-Ib (2.7-kg) weight loss; and a productive, chronic cough that
began 5 weeks ago. The client has not started the antibiotic regimen for latent tuberculosis.

Diagnostic Results
Chest x-ray
Lungs appear normal. There are no infiltrates, cavitation, or effusions.

The nurse is reinforcing teaching on the plan of care for active tuberculosis. For each of the statements made by the nurse, click to specify
if the statement is appropriate or not appropriate to include in the teaching.

A. A nurse will need to watch you take your medications
B. You should notify anyone that has frequently been in close contact with you
C. Weekly complete blood counts will track whether your antibiotics are effective
D. Alcohol use while taking these medications can increase your risk for liver damage

Correct Answer:

Rationale: The duration of standard treatment of active tuberculosis (TB) is long, typically over the course of months, which makes it difficult for many
clients to adhere to the medication regimen. Proper client teaching increases medication adherence and helps minimize transmission of the
infection to others
The nurse should reinforce the following teaching:
• Direct observational therapy, which is the process of directly handing the medications to clients and watching them swallow the
medications. This has been shown to increase medication adherence in clients with active TB.
• Notifying close contacts of clients with recent active TB infection to reduce transmission to others. The nurse should teach the client
to reduce contact with family members and keep living spaces well ventilated.
• Alcohol use increases the risk for liver damage while taking antibiotics for active TB (rifampin, isoniazid, pyrazinamide, ethambutol).
Monitoring antibiotic effectiveness with weekly blood counts is not appropriate because antibiotic effectiveness is evaluated with month
sputum tests until there are two consecutive negative results.

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.

The nurse reinforces discharge teaching to the client after laser peripheral iridotomy. Which of the following client statements indicate an understanding of the teaching? Select all that apply.

A. Gently pulling down my lower eyelid creates a pocket where I should administer the drops.
B. I will apply pressure over the inner corner of my eye after administering each medication
C. I will stop taking diphenhydramine because it can cause a glaucoma attack.
D. I will wait 5 minutes between administering each eye drop medication.
E. Touching my eye with the medication applicator may cause an infection.

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

Rationale: Laser peripheral iridotomy is a surgical intervention for acute angle-closure glaucoma (ACG) that involves creating a small hole in the iris to
prevent the drainage pathway from closing and improve movement of aqueous humor into regular outflow channels. Ophthalmic alpha-
adrenergic agonists (eg, apraclonidine, brimonidine) are administered postoperatively to reduce aqueous humor production and prevent an
elevation in intraocular pressure.
Important considerations for the administration of ophthalmic drops include:
• Pulling the lower eyelid down by gently pressing on the lower orbital bone to expose the conjunctival sac (Option 1)
• Applying pressure over the inner corner of the eye (eg, lacrimal duct) after each medication to avoid systemic absorption (Option 2)
• Waiting at least 5 minutes before instilling a different medication into the same eye to allow absorption of the first medication and to
avoid overflow with multiple drops (Option 4)
• Holding the dropper ½*% in (1-2 cm) above the conjunctival sac to prevent contamination of the dropper and infection of the eye
(Option 5)
Clients should also be instructed to consult with their health care provider before taking over-the-counter medications (eg, decongestants,
anticholinergics, antihistamines) because a subsequent episode of acute ACG may be triggered by certain medications (Option 3).

The nurse is caring for a 24-year-old client.
Nurses' Notes
Emergency Department
1300:
The client is brought to the emergency department after a motor vehicle collision in which the driver's side airbag deployed.
The client was driving the vehicle and was not restrained by a seat belt. The client reports shortness of breath and chest
pain on inspiration and expiration.

History and Physical
Body System ,Findings
Neurological,
Awake, alert, and oriented to person; pupils equal, round, and reactive to light and accommodation; client is
agitated and moves all extremities spontaneously but does not follow commands
Integumentary, Superficial lacerations to the face; diffuse bruising noted on upper extremities and chest wall
Pulmonary,
Vital signs: RR 30, SpOz 92% via nonrebreather mask; unilateral chest wall expansion observed on inspiration;
left-sided tracheal deviation noted; breath sounds diminished throughout the right lung field
Cardiovascular,
Vital signs: P 104, BP 90/58; S1 and S2 heard on auscultation; all pulses palpable; no extremity peripheral edema
noted
Psychosocial ,Alcohol odor noted on the client's breath

Select 5 findings that require immediate follow-up.

A. SpO, 92% via nonrebreather mask
B. unilateral chest wall expansion observed on
inspiration
C. left-sided tracheal deviation noted;
D. breath sounds diminished throughout the right lung
field
E. Superficial lacerations to the face
F. BP 90/58; S1 and S2 heard on auscultation; all pulses palpabl

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

Rationale: The nurse should immediately follow up on the following findings:
• Hypoxemia (eg, SpO, 92% on 100% oxygen [nonrebreather mask]) indicates an abnormality with ventilation and/or perfusion.
• Unilateral chest wall expansion on inspiration indicates one side of the lung is not inflating. This is usually due to lung collapse,
which could be due to an internal airway dysfunction (eg, mucous plug blocking air entry) or external compression (eg, pneumothorax).
• Tracheal deviation (ie, displacement of the trachea to one side) occurs when pressure from one side of the chest is higher than the
other, pushing the mediastinal structures to the side with less pressure. This is usually due to a large hemothorax or pneumothorax.
• Diminished breath sounds indicate the lung is not adequately expanding (eg, atelectasis, pneumothorax).
• Hypotension (eg, BP 90/58 mm Hg) occurs from several mechanisms, including compression of the heart (eg, cardiac tamponade)
and/or great vessels (eg, tension pneumothorax), inadequate ventricular filling between heartbeats (eg, supraventricular tachycardia),
volume depletion, and other conditions

History
Emergency Department
Admission: The client is brought to the emergency department for psychiatric evaluation after being found on the
roof of a seven-floor office tower screaming, "I am going to jump! Life is not worth living anymore!" The
client admits having attempted to jump off the building and wishes the police had not intervened. The
client reports that thoughts of self-harm have increased in intensity since a divorce 2 months ago. The
client's thoughts of self-harm are intermittent, with no reports of suicidal thoughts at the present time.
The client reports losing 10 pounds in the past month without trying, difficulty concentrating on tasks,
and feeling tired most of the day. No history of violence or trauma. The client reports recurring feelings
of worthlessness but no auditory/visual hallucinations or homicidal ideations.
Medical history includes seizures, but the client has not been taking prescribed levetiracetam. The client
reports smoking 1 pack of cigarettes per day for the past 3 years.
Vital signs: T 97.2 F (36.2 C), P 100, BP 153/70, RR 19
Laboratory Results
Laboratory Test and Reference Range,Admission
Urine drug screen
Cocaine
Negative
Positive,
Opioid
Negative
Negative,
Amphetamines
Negative
Negative,
Marijuana
Negative
Positive,
Phencyclidine
Negative
Negative,
Benzodiazepines
Negative
Negative,
Barbiturates
Negative
Negative,
Breathalyzer
No alcoho detected
0.00

The nurse has reviewed the information from the Laboratory Results. Which of the following conditions should the nurse suspect? Select all that apply.

A. Attention deficit hyperactivity disorder
B. Major depressive disorder
C. Posttraumatic stress disorder
D. Schizophrenia
E. Substance use disorder

Correct Answer: B,E

Rationale: Major depressive disorder (MDD) is characterized by a persistent (duration ≥2 weeks) depression in mood (eg, sadness,
social withdrawal) that interferes with daily life. This client has several clinical manifestations of MDD, including loss of interest
in daily activities, significant change in appetite or weight, persistent feelings of worthlessness, recurrent thoughts of self-harm,
inattention, and fatigue. MDD is a significant risk factor for suicide
Substance use disorder is the recurrent use of alcohol and/or recreational drugs that results in interpersonal dysfunction,
impaired control, and physical effects (eg, withdrawal). This client's urine drug screen is positive for cocaine and marijuana
Therefore, the nurse should further investigate the client's substance use (eg, amount, frequency, route of administration, date
of last use, perceived benefits, negative consequences)