Nokea
Nurses' Notes
Initial Clinic Visit
1100:
The client has experienced enuresis at night for the past 2 weeks and frequently requests to use the
bathroom while at school. The client was previously toilet trained with no nighttime bed wetting for 6 months;
the client recently relocated to a new home and school where the client lives with parents.
The parent reports that the client has recently demonstrated fatigue, irritability, and multiple behavioral
outbursts that resemble past temper tantrums. The client frequently reports feeling thirsty. No dysuria or
urinary hesitancy is reported.
Weight and height were in the 40th percentiles at the previous visit a year ago. Growth charts today show
the client's weight in the 20th percentile and height in the 40th percentile.
The client appears tired and irritable. Dry mucous membranes are noted with no increased work of
breathing. The lungs are clear to auscultation bilaterally. No cardiac murmur is heard.
Select below the 6 findings that require follow-up.
- A. enuresis at night
- B. recently relocated to a new home and school
- C. fatigue, irritability, and multiple
behavioral outbursts - D. frequently reports feeling
thirsty - E. weight in the 20th percentile
- F. Dry mucous membranes
- G. frequently requests to use
the bathroom while at school
Correct Answer: A,C,D,E,F,G
Rationale: The nurse should follow up on the following findings:
irritability may manifest as behavioral outbursts.
• Frequent urination and nocturnal enuresis: Frequent urination and involuntary voiding in a child who was previously
toilet trained for at least 6 months indicate excessive urination (ie, polyuria), which is a characteristic finding of multiple
medical conditions (eg, diabetes mellitus [DM], diabetes insipidus).
• Increased thirst and dry mucous membranes: Increased thirst (ie, polydipsia) and dry mucous membranes are signs
of dehydration. Dehydration in the presence of polyuria and weight loss is concerning for DM.
• Weight loss: Weight loss is a common finding in clients with DM because the body is unable to use glucose and instead
breaks down protein and fat stores for energy.
• Fatigue, irritability, and multiple behavioral outbursts: Fatigue and irritability in a client with polydipsia and polyuria
may indicate an energy deficit from altered glucose metabolism related to DM. In a 6-year-old client, fatigue and
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Nurses' Notes
Outpatient Clinic
Initial
visit
The child recently started attending a new preschool and hit a teacher during lunch. The parent says, "My
child has never been aggressive before but has always been particular about food."
The client was born at full term without complications and has no significant medical history. The child
started babbling at age 6 months, and the parent reports that the first words were spoken around age 12
months. The client then became quiet and "obsessed" with stacking blocks and organizing toys by color.
The child can kick a ball, draw a circle, pedal a tricycle, and now says two-word phrases. Vitals signs are
normal, and the client is tracking adequately on growth curves.
During the evaluation, the child sits in the corner of the room playing with blocks. The client does not follow
the parents gaze when the parent points to toys in the office. The child begins screaming and rocking back
and forth when the health care provider comes near.
The client returns to the clinic 6 months after starting behavioral therapy. Which statement by the parent indicates a need for further therapy?
- A. My child will eat but only if I cook the same meal every day.
- B. My child will make only brief periods of eye contact with the teacher.
- C. My child will occasionally play with other children at the park.
- D. My child will squeeze a soft toy instead of banging the head.
Correct Answer: A
Rationale: Early childhood intervention programs (eg, behavioral therapy) are a critical component for clients with autism spectrum
disorder and can have positive long-term effects on presenting symptoms and social skills. Therapy helps increase
communication and language skills; improve focus, social skills, memory, and academic functioning; and decrease problematic
behaviors through positive reinforcement and other behavioral approaches
When evaluating the outcomes of therapy, the nurse should recognize that clients who demonstrate narrowed, restricted
interests (eg, eating the same foods) indicate a need for additional therapy
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).
Complete the following sentence by choosing from the lists of options. Based on the clinical findings, the client is most at risk for--------------------- as evidenced by the client's------------------------
- A. vital signs
- B. peritonitis and sepsis
- C. fluid volume deficit and hypovolemic shock
- D. abdominal pain
- E. date of last menstrual period
- F. intraabdominal hemorrhage and hypovolemic shock
Correct Answer: C,A
Rationale: The client's findings are most aligned with diabetic ketoacidosis (DKA). When there is a lack of insulin to transport glucose into cells, glucose
accumulates, creating an osmotic gradient that leads to diuresis (polyuria) and fluid loss. If the hyperglycemia persists, the process continues
and the fluid volume deficit decreases cardiac output and perfusion to vital organs (hypotension). The heart rate increases (tachycardia)
to compensate for the decrease in cardiac output. Without immediate treatment, compensatory mechanisms eventually fail, and the client is
at risk for developing life-threatening hypovolemic shock
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).
For each potential finding below, click to specify if the finding is consistent with the disease process of diabetic ketoacidosis, ruptured appendix, or ruptured ectopic pregnancy. Each finding may support more than one disease process.
- A. Polyuria
- B. Vomiting
- C. Tachypnea
- D. Tachycardia
- E. Hyperglycemia
- F. Abdominal pain
Correct Answer:
Rationale: Diabetic ketoacidosis (DKA) is a complication of diabetes mellitus that results from lack of insulin. Insulin is required to transport glucose
into cells for energy, which means that lack of insulin leads to intracellular starvation despite the high level of glucose circulating in the blood
(hyperglycemia). Physiologic responses to hyperglycemia include osmotic diuresis (polyuria) for reduction of blood glucose levels and
breakdown of fat into acidic ketone bodies for energy. This leads to states of dehydration (as evidenced by tachycardia), electrolyte
imbalance, and metabolic acidosis. Ketoacidosis leads to tachypnea and deep respirations (Kussmaul respirations), as well as abdominal
pain and vomiting.
Appendicitis is an inflammation of the appendix often resulting from obstruction by fecal matter. Appendiceal obstruction traps colonic fluid
and mucus, causing increased intraluminal pressure and inflammation. This impairs perfusion of the appendix, resulting in swelling and
ischemia. Clinical manifestations include fever, abdominal pain, rebound abdominal tenderness, tachycardia, nausea, and vomiting.
Abdominal pain usually begins near the umbilicus and migrates to the right lower quadrant (eg, McBurney point). Tachypnea, as well as a
compensatory response, can be present, especially if there is a ruptured appendix or evidence of sepsis causing lactic acidosis (metabolic
acidosis).
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).
Laboratory Results
Laboratory Test and Reference Range, 0900
Glucose, serum (random)
≤200 mg/dL
(<11.1 mmol/L),
573 mg/dL
(31.8 mmol/L)
Potassium
3.5-5.0 mEq/L
(3.5-5.0 mmol/L),
5.7 mEq/L
(5.7 mmol/L)
The nurse has reviewed the information from the Laboratory Results. The client is transferred to an inpatient care facility. Which of the following orders should the nurse expect for the client? Select all that apply
- A. insulin IV infusion
- B. continuous cardiac monitoring
- C. hourly finger-stick blood glucose level
- D. 5% dextrose in 0.9% sodium chloride IV infusion
- E. rectal sodium polystyrene sulfonate
- F. strict intake and output monitoring
Correct Answer: A,B,C,G
Rationale: Management of diabetic ketoacidosis (DKA) initially focuses on IV fluid resuscitation to reverse hypovolemia and then correction of
hyperglycemia, electrolyte abnormalities, and acid-base imbalance. Appropriate interventions include:
• Continuous insulin IV infusion to correct hyperglycemia. IV insulin has a more rapid onset of action than subcutaneous insulin, whic
allows faster and more precise management of the blood glucose level (Option 1).
• Continuous cardiac monitoring to detect dyshythmias related to metabolic acidosis or electrolyte abnormalities (Option 2).
• Hourly finger-stick blood glucose level checks to monitor for treatment effectiveness and detect any hypoglycemia related to the
insulin infusion (Option 3).
• Isotonic IV fluid (eg, 0.9% sodium chloride) to replace fluid losses and strict intake and output monitoring to evaluate the
effectiveness of fluid resuscitation and monitor for signs of acute kidney injury (Option 6).
• Frequent monitoring of arterial blood gas levels and electrolyte levels.
The nurse is caring for a 20-year-old client.
Progress Notes
Clinic Visit
For the past week, the client has experienced flu-like symptoms, including low-grade fevers, headaches, nausea, vomiting, and, today,
diarrhea and dark urine. The client reports widespread itching but has no rash. Skin and scleras are jaundiced. No lymphadenopathy
is present, and the abdomen is nondistended with a palpable liver edge. The client returned from an international mission trip a few
weeks ago.
Vital signs are T 99.9 F (37.7 C), P 88, RR 18, BP 128/80, and SpOz 98% on room air.
Laboratory Results
Laboratory Test and Reference Range ,Current
Liver Function Tests
Total bilirubin, Increased
Alkaline phosphatase, Increased
Aspartate aminotransferase (AST), Increased
Alanine aminotransferase (ALT) ,Increased
Complete the following sentence by choosing from the lists of options. The nurse suspects the client has ----------- and should implement ----------- precautions.
- A. Influenza
- B. Droplet
- C. Contact
- D. Standard
- E. Hepatitis A
Correct Answer: D,E
Rationale: Hepatitis A is an infection that leads to widespread inflammation of the liver. Transmission occurs through the fecal-oral route and is commo
in areas with overcrowding and poor sanitation. Outbreaks frequently result from contaminated water or food, and the condition is seen
primarily in resource-limited countries. Symptoms develop abruptly, initially including nausea, vomiting, anorexia, fever, and right upper
quadrant pain. A few days later, dark urine (bilirubinuria) and/or pale stools (lacking bilirubin pigment) may be seen. These are usually
followed by jaundice and pruritus. In addition, laboratory results show elevated liver function tests.
Hand hygiene, especially after toileting and before meals, is the most important intervention for reducing the risk of hepatitis A infection.
Therefore, for a client hospitalized with hepatitis A, standard precautions (ie, hand hygiene, disinfection of equipment and surfaces) must be
implemented to prevent transmission. Additional precautions (eg, disposable gown, gloves) should be used as needed (eg, during procedure