The client is diagnosed with ischemic stroke. For each poten...

The nurse in the emergency department is caring for a 62-year-old client.
History and Physical
Neurological
The client is alert and oriented to time, place, person, and situation; the client reports sudden-onset right-sided facial drooping, speech is slurred; positive right-sided arm drift is seen
Eye, Ear, Nose, and Throat (EENT)
Bilateral pupils are equal, round, and reactive to light and accommodation

Pulmonary
Vital signs: RR 16, SpO, 95% on room air, lung sounds are clear bilaterally

Cardiovascular
Vital signs: T 99 F (37.2 C), P 86, BP 166/90; S1 and S2 are heard on auscultation; no murmurs are noted; the client has a history of hypertension

Musculoskeletal
Right-sided lower extremity weakness is seen

Endocrine
The client has diabetes mellitus

Psychosocial
The client reports drinking one glass of wine each evening with dinner, no tobacco use, and a history of major depression; the client takes sertraline.

Laboratory Results
During Admission
Blood Chemistry.
Glucose: 72 mg/dL (4.0 mmol/L)
Sodium: 133 mEq/L (133 mEq/L)
Chloride: 101 mEq/L (101 mmol/L)
Potassium: 3.7 mEq/L (3.7 mmol/L)

Laboratory Test and Reference Range
Blood Chemistry.
Glucose 74-106 mg/dL (4.1-5.9 mmol/L)
Sodium 136-145 mEq/L (136-145 mmol/L)
Chloride 98-106 mEq/L(98-106 mmol/L)
Potassium 3.5-5.0 mEq/L (3.5-5.0 mmol/L

Diagnostic Results
Admission
CT scan of the head without contrast
1830:
No areas of hemorrhage are noted

The client is diagnosed with ischemic stroke. For each potential intervention, click to specify if the intervention is indicated, not indicated for the care of the client.

A. Obtain a 12-lead ECG
B. Implement fall risk precautions
C. Offer the client small sips of water
D. Perform frequent neurologic assessments
E. Ensure tissue plasminogen activator is available
F. Apply sequential compression device to bilateral lower extremities

Correct Answer: A: Indicated, B: Indicated, C: Not Indicated, D: Indicated, E: Indicated, F: Indicated

Rationale: An ECG (A) monitors for cardiac causes of stroke. Fall precautions (B) address weakness-related risks. Frequent neurologic assessments (D) track stroke progression. tPA availability (E) is crucial for potential thrombolytic therapy. Sequential compression devices (F) prevent DVT in immobile patients. Oral intake (C) is contraindicated due to aspiration risk from dysphagia.

The nurse is assisting with a staff in-service regarding safe handling of controlled substances. For each behavior or finding, click to specify whether the behavior/finding is concerning or not concerning for possible drug diversion.

A. Excessively wastes controlled substances
B. Friends with many other nurses on the unit
C. Causes inventory discrepancies in the medication-dispensing machine
D. Frequently volunteers to administer medications for other nurses' clients
E. Asks for another nurse's password to the medication-dispensing system

Correct Answer: A,C,D,E

Rationale: A: Excessive wasting of controlled substances is concerning as it may indicate diversion for personal use or distribution. C: Inventory discrepancies suggest possible theft or misuse. D: Frequently volunteering to administer medications may provide opportunities for diversion. E: Requesting another nurse's password is a security breach and highly concerning for diversion.

The nurse is caring for a client at a women’s health clinic.
History & Physical
Labor and delivery unit
0800:
A 28-year-old nulliparous female comes to the clinic for confirmation of suspected pregnancy due to amenorrhea and a positive home pregnancy test. The client's current exercise regimen includes indoor cycling and outdoor running. The client reports nausea, vomiting, and breast tenderness. She has a 28-day menstrual cycle, and her last menstrual period was March 10- 17. The health care provider notes a bluish-purple vaginal mucosa and cervix during pelvic examination and confirms a 12-week intrauterine pregnancy by sonography. A fetal heart rate of 155/min is detected with handheld Doppler.

The client's last menstrual period was March 10-17. Unprotected intercourse occurred on March 24. The client's menstrual cycles are regular and occur every 28 days. Based on the Naegele rule, what is the estimated date of birth?

A. 3-Dec
B. 17-Dec
C. 24-Dec
D. 31-Dec

Correct Answer: B

Rationale: Using Naegele's rule (first day of LMP + 1 year - 3 months + 7 days), March 10, 2025 + 1 year = March 10, 2026 - 3 months = December 10, 2025 + 7 days = December 17, 2025.

The nurse in an inpatient mental health unit is caring for a 43-year-old client.
History
Admission:
The client comes to the inpatient psychiatric facility for an evaluation. The client is having distressing nightmares, flashbacks, and feelings of being "on edge" since a severe motor vehicle collision 6 months ago that resulted in the death of the client's sibling. The client blames self for the sibling's death and verbalizes feelings of guilt. The client reports an inability to sleep well and being quick to anger, both of which led to job loss and the client seeking help. The client reports a loss of interest in previously enjoyed activities, such as working out and interacting with friends. The client has started smoking cigarettes daily since the collision and typically consumes ≥4 alcoholic beverages per day. Mental status examination reveals an irritable, guarded, and easily distracted mood. The client's appearance is well- kept, and grooming and hygiene are appropriate. The client’s speech is hyperverbal yet coherent, and thought process is organized. The client admits to feelings of hopelessness after the death of the sibling. The client reports occasionally seeing "shadows" but no visual hallucinations. The client has no homicidal ideations or history of violence toward others.
Vital signs: P 78, RR 17, BP 132/78.

The nurse should prioritize interventions for due to the risk of

A. Anxiety
B. Irritability
C. Alcohol withdrawal
D. Complicated grieving
E. Self harm
F. Panic attacks
G. Angry outbursts

Correct Answer: C

Rationale: The client's consumption of â‰¥4 alcoholic beverages per day indicates a risk of alcohol withdrawal, which can be life-threatening and requires prioritized intervention.

The nurse in the emergency department is caring for a 62-year-old client.
Progress Notes
Emergency Department
0900: The client is brought to the emergency department by a family member after being found confused and lethargic. On arrival, the client is obtunded and does not respond to verbal stimuli.
Medical history includes major depressive disorder and chronic neck and back pain after a motor vehicle collision 2 years ago. The family member states that the client takes multiple medications but does not know which kind. The client was divorced a few months ago.
Physical examination shows 1-mm pupils, shallow breathing, and reduced bowel sounds. Fingerstick blood glucose is 78 mg/dL (4.3 mmol/L). ECG reveals normal sinus rhythm. Breath alcohol test is negative.
Vital signs: T 98.1 F (36.7 C), P 62, RR 8, BP 80/40, SpO, 94% on room air.
1800:
The client is awake, alert, and oriented to person, place, time, and situation. The client is experiencing severe withdrawal symptoms and is admitted for supervised detoxification.

Laboratory Results
Urine Drug Screen
On admission
Cocaine- Negative
Opioids- Positive
Amphetamines- Negative
Marijuana- Positive
Phencyclidine-Negative
Benzodiazepines- Negative
Barbiturates- Negative
Laboratory Test and Reference Range
Cocaine- Negative
Opioids- Negative
Amphetamines- Negative
Marijuana- Negative
Phencyclidine- Negative
Benzodiazepines- Negative
Barbiturates- Negative

The nurse is evaluating teaching for the client who is newly prescribed methadone for opioid use disorder. Which of the following client statements indicate that the teaching has been effective? Select all that apply.

A. I can take an additional tablet if my cravings are not managed with one tablet.
B. I need to rise slowly to a standing position while taking this medication.
C. I should not consume alcohol while taking this medication.
D. I should stop taking this medication if I notice adverse effects.
E. I will contact the health care provider if I experience dizziness or heart palpitations.

Correct Answer: B,C,E

Rationale: B: Rising slowly prevents orthostatic hypotension, a methadone side effect. C: Avoiding alcohol reduces CNS depression risk. E: Reporting dizziness or palpitations ensures timely management of adverse effects. A is incorrect as extra doses require provider approval, and D is incorrect as stopping abruptly can cause withdrawal.

Which client finding requires immediate follow-up by the nurse?

A. Hopelessness
B. Hyperverbal speech
C. Insomnia
D. Irritability

Correct Answer: A

Rationale: Hopelessness is a critical finding indicating a risk for suicide or severe depression, requiring immediate assessment and intervention in a client with post-traumatic stress symptoms and recent life stressors.