Select the findings that indicate the client is experiencing...

A nurse caring for a client in the outpatient mental health clinic
Vital signs
2 months ago:
BP 128/78 mm Hg
Heart rate 76/min
Respiratory rate 17/min
Today
BP 169/91 mm HG
Heart rate 78/min
Respiratory rate 18/min
Nurses' Notes
Today
Client states, "I'm feeling much better." They report less fatigue, even though they have
difficulty sleeping. Client reports they are not sad anymore but are experiencing more frequent
headaches. Client continues to deny any suicidal ideation.

Select the findings that indicate the client is experiencing adverse effects of the medication.

A. Client states, 'I am feeling much better'
B. Difficulty sleeping
C. Client continues to deny any suicidal ideation
D. BP 169/91 mm HG
E. Respiratory rate 18/min

Correct Answer: B,D

Rationale: Hypertension and difficulty sleeping are potential side effects of certain medications.

A nurse in an outpatient clinic is caring for a client.
Assessment
0840:
Client is calm and cooperative. Skin warm and dry. No rash noted. Lung sounds clear. Abdomen
soft to palpation with fundal height at 20 cm. Fetal heart rate 150/min. Bowel sounds active in all
four quadrants. No edema to lower extremities. Client denies visual changes or severe headaches.
Weight gain of 1.8 kg (4 lb) since last visit. Small amount of mucoid discharge noted on perineal
pad
Laboratory Results
0900:
Urine dipstick:
pH 6.0 mg/d (4.6 to 8 mg/dL)
Specific Gravity 1.022 (1.010 to 1.025)
Leukocyte esterase negative (Negative)
Nitrite negative (Negative)
Protein trace negative (Negative)
Glucose negative (Negative)
Ketones none (None)
Bilirubin none (None)
Blood none (None)
Nurses' Notes
0830:
Client reports to clinic for monthly prenatal visit. Client is at 20 weeks of gestation. Since last
visit, client reports concerns about the occurrence of intermittent mild backaches, increased
heartburn, generalized itching, and vaginal discharge.
Vital Signs
0830:
BP 124/68 mm Hg
Heart rate 80/min
Temperature 37° C (98.6° F)
Respiratory rate 16/min
Weight 67.1 kg (148 lb)

Which of the following statements should the nurse include in the client's teaching?

A. Take hot showers to help relieve itching
B. Wear flat or low-heeled shoes
C. You can douche twice weekly
D. Wear loose-fitting clothing
E. Try using an abdominal support belt
F. You should avoid fried foods
G. Eat two large meals a day

Correct Answer: B,D,F

Rationale: Wearing flat shoes, wearing loose-fitting clothes, and avoiding fried foods are beneficial practices during pregnancy.

A nurse is caring for a client
History and Physical
Day 1,0900:
A 52-year-old client brought to emergency department by adult child. Client is alert and oriented
to person and time but does not know where they are. No history of substance use according to
client's adult child. Client exhibits constant movements and poor concentration. Hair and
clothing are unclean, appears to be listening to unseen others. Skin turgor poor.
Nurses Notes
Day 1. 0915
The client's adult child reports the client has not slept for 2 days and has become obsessed with
cleaning the house and hosting parties. At times the client is overly joyous and has a very
elevated sense of self-confidence. The adult child states that the client has also demonstrated
very impulsive spending habits and expresses concern about the client giving away large sums
of money to others
The client's speech is very pressured, disorganized, and loud. Client unable to recall the last time
they ate
Vital Signs
Day 1, 0905:
Temperature 37.1° C (98,8° F)
Heart rate 120/min
Respiratory rate 19/min
BP 138/88 mm Hg
Oxygen saturation 98% on room air

Select the 4 findings that require immediate follow up

A. Hallucinations
B. Heart rate
C. Sleep patterns
D. Skin turgor
E. Hygiene

Correct Answer: A,B,C,D

Rationale: The correct answer is A, B, C, and D. Hallucinations (A) may indicate a serious health issue needing immediate attention. Abnormal heart rate (B) could signify a cardiac problem. Disrupted sleep patterns (C) may indicate underlying health conditions. Reduced skin turgor (D) can signal dehydration or malnutrition. Choices E, F, and G are not typically indicative of immediate follow-up needs in this context.

A nurse is caring for a client who experienced a traumatic brain injury 72 hours ago.

Which finding should the nurse identify as a potential indication of increased intracranial pressure?

A. Increasingly severe headache
B. Bradycardia and hypertension
C. Dilated, non-reactive pupils
D. All of the above

Correct Answer: D

Rationale: The correct answer is D, "All of the above." Increasingly severe headache is a common symptom of increased intracranial pressure due to brain tissue compression. Bradycardia and hypertension can occur as a result of increased intracranial pressure affecting the autonomic nervous system. Dilated, non-reactive pupils may indicate brainstem compression. Therefore, all of these findings are potential indications of increased intracranial pressure. Choices A, B, and C all individually point towards different manifestations of increased intracranial pressure, making them incorrect if considered in isolation.

A nurse is planning to delegate to an AP the fasting blood glucose testing for a client who has diabetes mellitus.

Which of the following action should the nurse take?

A. Determine if the AP has the skills to perform the test.
B. Help the AP performed the blood glucose test
C. Assign the AP to ask the client is taking his diabetic medication today
D. Have AP check the medical record for prior blood glucose test results

Correct Answer: A

Rationale: The correct answer is A because the nurse should first assess if the AP has the necessary skills to perform the blood glucose test. This step is crucial to ensure patient safety and accurate test results. Helping the AP perform the test (B) without assessing their skills can lead to errors. Assigning the AP to ask about medication (C) is not directly related to the task at hand. Having the AP check records (D) is important but should come after confirming their skills. The other choices are not relevant to the immediate situation.

The nurse is continuing to care for the client.
Provider Prescriptions Day 1,
1030
Admit to obstetrical unit.
Serum magnesium level per facility policy 24 hr urine
for total protein and creatinine Insert indwelling
urinary catheter Continuous external fetal monitoring
Administer loading dose of magnesium sulfate 4 g via Intermittent IV bolus over 20 min
followed by a maintenance dose of 2 g/hr
Lactated Ringer's 50 ml/tr via continuous iV infusion Betamethasone
12 mg IM X2 doses given 24 hr apart
Labetalol 20 mg IV bolus now, then 100 mg PO twice dally starting at 2000 Vital signs every 30
min
Acetaminophen 650 mg PO every 6 hr PRN pain Hourly intake and
output

The provider has admitted the client to the inpatient obstetrics unit and written prescriptions based on the client's condition. The action the nurse should take first is------followed by ----------

A. evaluating the fetal heart rate tracing
B. monitoring urine output
C. Checking the client's blood pressure
D. administering labetalol
E. Starting the continuous IV infusion
F. inserting an indwelling urinary catheter

Correct Answer: C,D

Rationale: The correct first action is to check the client's blood pressure (Choice C) as it is essential to assess the client's immediate physiological status. High blood pressure in obstetric patients can lead to severe complications. Administering labetalol (Choice D) is the next step if the blood pressure is elevated, as it is a commonly used medication to manage hypertension in pregnancy. Choices A, B, E, and F are important interventions but should be prioritized after addressing the client's blood pressure as they are not directly related to the immediate risk of hypertensive crisis.