Nokea
The nurse is caring for a 43-year-old client.
Nurses' Notes Vital Signs
Emergency Department
0800: A 43-year-old client comes to the emergency department due to lower back pain and bilateral leg weakness. The client reports that the weakness began 3 days ago in the feet and has gradually worsened. The client sought treatment today after becoming "so weak that I fell while walking" and noticing new hand weakness and difficulty swallowing. Back pain radiates down both legs and is rated as 5 on a scale of 0-10. The client recently recovered from an illness with flu-like symptoms. The client reports a history of hypertension and takes no medications. Assessment of the lower extremities reveals muscle strength of 2/5 and decreased sensation to pinprick. Achilles tendon and patellar reflexes are decreased
Select the 4 complications the client is most at risk for developing.
- A. Aspiration pneumonia
- B. Pressure injuries
- C. Respiratory failure
- D. Sepsis
- E. Venous thromboembolism
Correct Answer: A,B,C,E
Rationale: Guillain-Barré syndrome risks include aspiration , pressure injuries , respiratory failure , and thromboembolism due to immobility and respiratory involvement.
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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.
The nurse is caring for a 75-year-old female client. Nurses' Notes Laboratory Results Diagnostic Results Emergency Department
The client is transferred to the emergency department from a skilled nursing facility for a 3-day history of left lower quadrant abdominal pain rated 8 on a scale of 0-10, loss of appetite, and nausea. Although the client has a history of chronic constipation, she has had 2 or 3 loose stools daily for 1 week. The client reports tenderness on deep palpation of the left lower quadrant. There is an area of blanchable redness on the coccyx. The stool is positive for occult blood.
The client has residual left-sided weakness from an ischemic stroke 2 years ago and ambulates with a walker. The client reports falling several times in the past 6 months; the last fall was 3 weeks ago No ecchymosis or injuries are noted. The client had a hysterectomy and salpingo-oophorectomy for uterine fibroids 20 years ago. Vital signs are T 100 F (37.8 C), P 98, RR 17, BP 126/68, and SpOz 97% on room air.
Medical-Surgical Unit: 4 Days Later
The client continues to experience left lower quadrant pain, decreased appetite, and nausea. Today, she developed chills. Stool frequency has not increased. Severe tenderness is noted in the left lower quadrant, and a mass is palpable. Vital signs are T 101.3 F (38.5 C), P 112, RR 17, BP 110/80, SpO, 97% on room air.
For each potential intervention, click to specify the intervention is expected or not expected for the care of the client at this time.
- A. Keep NPO
- B. Maintain IV fluids
- C. Administer antibiotics
- D. Apply heating pad to abdomen
- E. Verify consent for abdominal surgery
Correct Answer: A,B,C
Rationale: NPO status , IV fluids , and antibiotics are expected for acute diverticulitis. Heating pads worsen inflammation, and surgery is not immediate.
The nurse is caring for a 68-year-old client who is brought to the emergency department due to confusion.
History and Physical Body System Findings
General- Client's adult child reports the confusion started this morning, following 3 days of fever and productive cough; medical history includes small bowel resection 10 days ago, chronic heart failure, and coronary artery disease
Neurological- Client is drowsy and oriented to person only, but intermittently agitated Integumentary- Small abdominal surgical incision is present over lower left quadrant, edges are well approximated, and no redness or drainage is noted
Pulmonary- Vital signs are RR 24 and SpO 90% on room air; labored breathing is observed, and crackles and diminished breath sounds are auscultated over right lower chest; client is expectorating yellow sputum; history includes smoking a pack of cigarettes daily for the past 40 years
Cardiovascular- Vital signs are T 102.9 F (39.4 C), P 110, and BP 110/70; S1 and S2 are heard on auscultation; bilateral lower extremity edema is 1+; ECG shows sinus tachycardia
Gastrointestinal- Normoactive bowel sounds are auscultated; client's last bowel movement was 1 day ago
Genitourinary- Client voided concentrated yellow urine
For each finding below, click to specify if the finding is consistent with the disease process of pneumonia or pulmonary embolism.
- A. Dyspnea
- B. Confusion
- C. High fever
- D. Recent surgery
- E. Smoking history
- F. Purulent sputum
Correct Answer: A,B,C,D,E
Rationale: Dyspnea , confusion , and smoking occur in both. Fever and sputum are specific to pneumonia, surgery to embolism.
The nurse is contacting a client at 28 weeks gestation to review laboratory results and schedule a follow-up prenatal visit. Laboratory Results Laboratory Test and Reference Range 12 Weeks Gestation 26 Weeks Gestation 28 Weeks Gestation
WBC (prostent) 5,000-1多份 (5.0-15.0 × 10°/L) 8,900/mm3 (8.9 × 10°/L) 16,500 /mm° (16.5 × 10%/L)
Hemoglobin (pregnant) 11-16 g/dL (110-160 g/L) 13 g/dL (130 g/L) 10.8 g/dL (108 g/L) Hematocrit (pregnant) 33%-47% (0.33-0.47) 39% (0.39) 32% (0.32)
Chlamydia Negative Positive Negative Hemoglobin A1c 4.0%-5.9% 5.1%
1-hour oral glucose challenge test <140 mg/dL (7.8 mmol/L) 175 mg/dL (9.7 mmol/L)
3-hour oral glucose tolerance test Fasting: <110 mg/dL (6.1 mmol/L) 1 hour: <180 mg/dL (10.0 mmol/L) 2 hour: <140 mg/dL (7.8 mmol/L 3 hour: <70-115 mg/dL (<6.4 mmol/L) Fasting: 115 mg/dL (6.4 mmol/L) 1 hour: 205 mg/dL (11.4 mmol/L) 2 hour: 162 mg/dL (9.0 mg/dL) 3 hour: 135 mg/dL (7.5 mg/dL)
The client, gravida 3 para 2, at 38 weeks gestation is admitted at 0700 for induction of labor. Which action is a priority?
- A. Change primary fluids to dextrose 5% in 0.9% sodium chloride
- B. Discontinue the insulin infusion
- C. Obtain a capillary blood glucose level
- D. Perform a cervical examination
Correct Answer: C
Rationale: Checking blood glucose is critical during labor induction to manage gestational diabetes.
The nurse is caring for a 40-year-old client.
History Admission:
The client is brought to the psychiatric emergency department by ambulance after being observed walking in the street and shouting at vehicles. The client states that aliens are trying to attack him and that he is now on a mission to find and kill them. The clients mother says that last year he believed that he was being watched by an unidentified government agency and subsequently broke up with his girlfriend, quit his job, and disconnected his phone. The mother has noticed that he no longer seems to care about activities that used to interest him, and last month she discovered that he had moved into the family garden shed with his dog.
On examination, the client is malodorous and disheveled and laughs for no apparent reason. He appears anxious, avoids eye contact, and shows little emotion. His answers are very brief, and he asks if the interview is being secretly recorded. The client's speech is difficult to follow, and he repeatedly says in a monotone voice, "I said I'll find them." He later becomes angry and refuses to sit in a chair for the interview. I'll find them." He later becomes angry and refuses to sit in a chair for the interview.
For each finding, click to specify whether the finding indicates that the client's status has improved or not improved.
- A. Client is seen talking alone in the hallway
- B. Client is seen playing board games with peers
- C. Client asks the technician for hygiene supplies
- D. Client states, 'The voices are a part of my illness.'
- E. Client refuses to take medication from a new nurse
- F. Client is willing to eat food that is prepackaged only
Correct Answer: B,C,D
Rationale: Social interaction , hygiene requests , and insight into illness show improvement. Talking alone , medication refusal , and food paranoia indicate ongoing symptoms.