Nokea
History and physical
Flow sheet
Nurses’ Notes
Imaging studies 1935
A 70-year-old female presents to the emergency department through triage with a noticeable facial droop and garbled speech. After having a few drinks at a local seafood restaurant, the patient’s husband noticed his wife’s speech became difficult to understand
Specify which findings indicate early interventions for an ischemic stroke were effective? Focused assessment area: Neurological, Muscoskeletal, Psychosocial
- A. Neurological: Drinks with repetitive cough, Speaks in short sentences, Decorticate posturing; Muscoskeletal: Flaccidity of left arm, Ambulates with a walker, Passive range of motion on left leg; Psychosocial: Fits of laughter, Tearful sharing of stories, Angry outburst
- B. Neurological: Speaks in short sentences; Muscoskeletal: Ambulates with a walker; Psychosocial: Tearful sharing of stories
Correct Answer: B,B,B
Rationale: Neurological: Speaking in short sentences indicates improved speech from garbled to intelligible. Muscoskeletal: Ambulating with a walker shows regained mobility. Psychosocial: Tearful sharing of stories reflects normal emotional expression and preserved memory, indicating effective early interventions.
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The nurse is providing dietary instructions for a client who is being discharged after passing a calcium oxalate renal stone. Which food should the nurse instruct the client to avoid?
- A. Sweet potatoes.
- B. Spinach salad.
- C. Bananas.
- D. Fish.
Correct Answer: B
Rationale: Spinach salad is high in oxalate, which can combine with calcium in the urine to form stones, increasing the risk of recurrence.
A client is hospitalized with an inflammatory bowel disease (IBD) exacerbation and is being treated with a corticosteroid. The client develops a rigid abdomen with rebound tenderness. Which action should the nurse take?
- A. Measure capillary glucose level.
- B. Encourage ambulation in the room.
- C. Monitor for bloody diarrheal stools.
- D. Obtain vital sign measurements.
Correct Answer: D
Rationale: Obtaining vital sign measurements is the priority action for a client with a rigid abdomen and rebound tenderness, indicating peritonitis, a serious complication of IBD. Vital signs can reveal signs of infection, inflammation, shock, and organ failure, guiding appropriate interventions and treatments.
In assessing a client with ulcers on the lower extremity, which findings indicate that the ulcers are likely to be of venous, rather than arterial, origin?
- A. Irregular ulcer shapes and severe edema.
- B. Hairless lower extremities and cool feet.
- C. Black ulcers and dependent rubor.
- D. Absent pedal pulses and shiny skin.
Correct Answer: A
Rationale: Irregular ulcer shapes and severe edema are characteristic of venous ulcers, caused by impaired venous return and increased capillary pressure.
A client with gouty arthritis reports tenderness and swelling of the right ankle and great toe. The nurse observes the area of inflammation extends above the ankle area. The client receives prescriptions for colchicine and indomethacin. Which instruction should the nurse include in the discharge teaching?
- A. Return for periodic liver function studies.
- B. Massage joints to relax muscles and decrease pain.
- C. Limit use of mobility equipment to avoid muscle atrophy.
- D. Substitute natural fruit juices for carbonated drinks.
Correct Answer: A
Rationale: Returning for periodic liver function studies is important because colchicine and indomethacin can cause liver toxicity, which should be monitored through regular blood tests.
A client has an absolute neutrophil count (ANC) of 500/mm³ (0.5 x 10â¹/L) after completing chemotherapy. Which intervention is most important for the nurse to implement?
- A. Review need for pneumococcal vaccine.
- B. Implement bleeding precautions.
- C. Assess vital signs every 4 hours.
- D. Place the client in protective isolation.
Correct Answer: D
Rationale: Placing the client in protective isolation is the most important intervention to prevent infections, as a low ANC indicates a high risk of bacterial and fungal infections.