Nokea
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 2-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 parent's 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.
Emergency Department
3 years The client is brought to the emergency department by the parents, who report that the child became upset
later
and started banging the head against the wall several times. The parents report that the client has had
these episodes frequently; however, this time, the child was injured. The client has a laceration on the
forehead and is admitted for 24-hour observation.
The client is newly prescribed aripiprazole for autism spectrum disorder. The nurse is reinforcing teaching to the client's parents. Which statement by the nurse is appropriate?
- A. Abruptly stopping the medication can cause withdrawal symptoms
- B. Aripiprazole will cure your child's autism.
- C. Restlessness is an expected side effect and will eventually subside.
- D. This medication will eliminate your child's self-harm behaviors
Correct Answer: A
Rationale: Aripiprazole, an atypical antipsychotic medication, is used in the treatment of irritability associated with autism spectrum
disorder (ASD), schizophrenia, bipolar disorder, and other mental health disorders. Aripiprazole works as a partial agonist at
the serotonin and dopamine receptor sites. As a result, the medication has a more favorable safety profile (eg, fewer metabolic
effects, lower potential for prolactin release) than other antipsychotics; however, it may be less effective in symptom relief.
Clients taking aripiprazole should be reminded to not abruptly stop taking the medication because it can cause withdrawal
symptoms (eg, anxiety, dizziness, tachycardia, diaphoresis, insomnia, vomiting) and may exacerbate previous symptoms.
These medications should be weaned over time and substituted with an alternate medication under the supervision of a health
care provider
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History and Physical
Body System,Findings
General
Client has history of coronary artery disease, hypertension, hyperlipidemia, diverticulosis, and
osteoarthritis; Helicobacter pylori infection 2 years ago; client reports taking over-the-counter
ibuprofen every 8 hours for left knee pain for the past 2 weeks; daily medications include aspirin,
carvedilol, lisinopril, and atorvastatin
Neurological
Alert and oriented to person, place, time, and situation
Pulmonary
Vital signs: RR 20, SpO 96% on room air, lung sounds clear bilaterally; no shortness of breath;
client smokes 1 pack of cigarettes per day and smokes marijuana 1 or 2 times weekly
Cardiovascular
Vital signs: P 110, BP 90/62; no chest pain; S1 and S2 heard on auscultation; peripheral pulses
2+; client states feeling lightheaded and reports passing out about 1 hour ago
Gastrointestinal
Abdominal pain rated as 4 on a scale of 0-10; one episode of hematemesis; two episodes of
large, black, liquid stools in the morning
Musculoskeletal
Examination of the knees shows crepitus that is worse on the left; no swelling, warmth, or
erythema; range of motion is normal
Psychosocial
Client reports drinking 1 or 2 glasses of wine per day
Complete the following sentence/sentences by choosing from the list/lists of options.This client is most likely experiencing gastrointestinal bleeding related to ----------
- A. Diverticulosis
- B. Ulcerative colitis
- C. Peptic Ulcer disease
Correct Answer: C
Rationale: The client is most likely experiencing gastrointestinal GI) bleeding related to peptic ulcer disease (PUD).
The clients symptoms are most consistent with upper Gl bleeding. PUD is one of the most common causes of upper GI
bleeding due to erosion and ulceration of the protective layers (ie, mucosa) of the upper Gl tract (eg, esophagus, stomach,
duodenum). Impaired mucosa allows digestive enzymes and stomach acid to break down underlying tissues, leading to GI
bleeding and perforation. The client has multiple risk factors for PUD, including history of Helicobacter pylori infection, chronic
NSAID use, smoking, and daily alcohol consumption.
History
Emergency Department
Admission: The client is brought to the emergency department for psychiatric evaluation after being found on the
roof of a seven-floor office tower screaming, "I am going to jump! Life is not worth living anymore!" The
client admits having attempted to jump off the building and wishes the police had not intervened. The
client reports that thoughts of self-harm have increased in intensity since a divorce 2 months ago. The
client's thoughts of self-harm are intermittent, with no reports of suicidal thoughts at the present time.
The client reports losing 10 pounds in the past month without trying, difficulty concentrating on tasks,
and feeling tired most of the day. No history of violence or trauma. The client reports recurring feelings
of worthlessness but no auditory/visual hallucinations or homicidal ideations.
Medical history includes seizures, but the client has not been taking prescribed levetiracetam. The client
reports smoking 1 pack of cigarettes per day for the past 3 years.
Vital signs: T 97.2 F (36.2 C), P 100, BP 153/70, RR 19
Laboratory Results
Laboratory Test and Reference Range,Admission
Urine drug screen
Cocaine
Negative
Positive,
Opioid
Negative
Negative,
Amphetamines
Negative
Negative,
Marijuana
Negative
Positive,
Phencyclidine
Negative
Negative,
Benzodiazepines
Negative
Negative,
Barbiturates
Negative
Negative,
Breathalyzer
No alcoho detected
0.00
Complete the following sentence/sentences by choosing from the list/lists of options. he nurse should prioritize interventions for------- due to the client's -----
- A. Malnutrion
- B. Suicidal Behavior
- C. Substance withdrawal
- D. Recent weight loss
- E. Thoughts of self harm
- F. History of cocaine and marijuana use
Correct Answer: B,E
Rationale: The nurse should prioritize interventions for suicidal behavior due to the client's thoughts of self-harm.
This client has several predisposing factors that increase the risk of suicide, including a psychiatric disorder, previous suicide
attempt, stressful life events (eg, divorce), and substance use. However, the strongest single factor predictive of suicide is the
history of a prior suicide attempt (eg, jumping off a building). The nurse should anticipate implementation of suicide
precautions (eg, 1-to-1 observation).
History
Labor and Delivery Unit
Admission: The client, gravida 1 para 0, at 16 weeks gestation with a twin pregnancy reports nausea and vomiting for the past
several weeks. The client also reports dry heaving, increasing weakness, light-headedness, and an inability to tolerate
oral intake for the past 24 hours. In addition, the client has had occasional right-sided, shooting pain from the abdomen
to the groin that occurs with sudden position changes. The pain quickly resolves without intervention per the client's
report. She has had no contractions or vaginal bleeding and has felt no fetal movement during this pregnancy. The
client has a history of childhood asthma and is currently taking no asthma medications. The client reports no other
pregnancy complications.
Physical
Prepregnancy,12 Weeks Gestation 16 Weeks Gestation(Prenatal Visit),(Labor and Delivery Admission)
Height ,5 ft 5 in (165.1 cm),5 ft 5 in (165.1 cm)|, 5 ft 5 in (165.1 cm)
Weight, 145 lb (65.8 kg),148 lb (67.1 kg),138 lb (62.6 kg)
BMI, 24.1 kg/m2, 24.6 kg/m2,23.0 kg/m2
Vital Signs
12 Weeks Gestation(Prenatal Visit),16 Weeks Gestation(Labor and Delivery Admission)
T,98.7 F (37.1 C),99.8 F (37.7 C)
P,70,101
RR,14,18
BP,122/78,90/55
SpO2,99% on room air,96% on room air
Laboratory Results
Laboratory Test and Reference Range, 16 Weeks Gestation
Blood Chemistry.
Sodium
136-145 mEq/L
(136-145 mmol/L)|,
136 mEq/L
(136 mmol/L)
Potassium
3.5-5.0 mEq/L
(3.5-5.0 mmol/L),
2.7 mEq/L
(2.7 mmol/L)
TSH
0.3-5.0 uU/mL
(0.3-5.0 mU/L),
0.4 pu/mL
(0.4 mU/L)
Hematology.
Hemoglobin (pregnant)
>11 g/dL
(>110 g/L),
16 g/dL
(160 g/L)
Hematocrit (pregnant)
>33%
(>0.33),
49%
(0.49)
Urinalysis
Specific gravity
1.005-1.030
1.030,
Ketones
Not present,
Present
Giucose
Not present,
Not present
Nitrites
Not present,
Not present
The client is diagnosed with hyperemesis gravidarum and is planning care with the registered nurse. For each potential intervention, click to specify if the intervention is indicated or contraindicated for the care of the client.
- A. Give clear liquids
- B. Weigh the client daily
- C. Obtain a 12-lead ECG
- D. Administer enteral nutrition
- E. Initiate a large-bore peripheral IV
- F. Document strict intake and output
- G. Auscultate the fetal heart rate intermittently
Correct Answer:
Rationale: When caring for clients with hyperemesis gravidarum (HG), the primary goal is to alleviate vomiting, replenish fluids, and correct electrolyte
and nutritional imbalances. Once completed, resumption of oral intake can be attempted. Interventions that are indicated at this time
include:
• Weighing the client daily to monitor for additional weight loss
• Obtaining a 12-lead ECG to monitor for cardiac changes related to electrolyte imbalances (eg, hypokalemia)
• Initiating a large-bore peripheral IV (eg, 18-gauge) to allow for administration of fluids and medications
• Documenting strict intake and output (eg, emesis, urinary output) to monitor hydration status and kidney function
• Auscultating the fetal heart rate intermittently (eg, twice daily, once per shift) to verify fetal status. (Continuous fetal heart rate
monitoring is not indicated at this gestational age.)
Many clients with HG cannot tolerate anything by mouth and are typically placed on a short period of gut rest (ie, NPO status), if hospitalized.
Therefore, giving clear liquids is contraindicated during the initial treatment phase of HG but should be offered once nausea and vomiting
have stopped. For the same reasons, administering enteral nutrition (eg, tube feeding) is contraindicated initially for this client and is not
anticipated unless feedings by mouth and other treatment measures fail.
Nurses' Notes
Clinic Visit
0915:
The client reports substernal chest discomfort and intermittent palpitations that began this morning. Medical
history includes coronary artery disease and stable angina. Daily medications include aspirin, metoprolol,
atorvastatin, and lisinopril. The client has been traveling for the past week and ran out of one of the
medications.
Vital Signs 0915
T
98.2 F (36.8 C)
P
116
RR
16
BP
138/89
SpOz
98% on room air
The nurse is caring for a 65-year-old client in the clinic. Complete the following sentence by choosing from the list of options.The nurse suspects that the clients condition is most likely related to the abrupt discontinuation of-----------------
- A. Lisinopril
- B. Metoprolol
- C. Atorvastatin
Correct Answer: B
Rationale: Beta-adrenergic antagonists, also known as beta blockers (eg, metoprolol, atenolol), are commonly used to treat
hypertension, heart failure, and anxiety. Beta blockers reduce cardiac workload by inhibiting the action of catecholamines (eg,
epinephrine, norepinephrine) on beta-adrenergic receptors in the heart. This slows electrical conduction through the heart,
which decreases heart rate and blood pressure.
Abrupt discontinuation of beta blockers can result in rebound hypertension, angina, palpitations, myocardial infarction,
arrhythmias (eg, tachycardia, ventricular tachycardia), or sudden death. These discontinuation-associated risks are caused
by increased beta-adrenergic receptor sensitivity to circulating catecholamines, resulting in an increased sympathetic
response. Withdrawal symptoms should resolve after resumption of the medication.
History
Emergency Department
Admission: The client is brought to the emergency department for psychiatric evaluation after being found on the
roof of a seven-floor office tower screaming, "I am going to jump! Life is not worth living anymore!" The
client admits having attempted to jump off the building and wishes the police had not intervened. The
client reports that thoughts of self-harm have increased in intensity since a divorce 2 months ago. The
client's thoughts of self-harm are intermittent, with no reports of suicidal thoughts at the present time.
The client reports losing 10 pounds in the past month without trying, difficulty concentrating on tasks,
and feeling tired most of the day. No history of violence or trauma. The client reports recurring feelings
of worthlessness but no auditory/visual hallucinations or homicidal ideations.
Medical history includes seizures, but the client has not been taking prescribed levetiracetam. The client
reports smoking 1 pack of cigarettes per day for the past 3 years.
Vital signs: T 97.2 F (36.2 C), P 100, BP 153/70, RR 19
Laboratory Results
Laboratory Test and Reference Range,Admission
Urine drug screen
Cocaine
Negative
Positive,
Opioid
Negative
Negative,
Amphetamines
Negative
Negative,
Marijuana
Negative
Positive,
Phencyclidine
Negative
Negative,
Benzodiazepines
Negative
Negative,
Barbiturates
Negative
Negative,
Breathalyzer
No alcoho detected
0.00
Nurses' Notes
Inpatient: Mental Health Unit
0900:
1200:
1500:
2000:
The client is inattentive, withdrawn, and depressed with low energy. The client's appearance is disheveled
with noted body odor. The client is declining breakfast and does not participate in group therapy. Education
was provided about the importance of participating in the treatment plan, and the client was encouraged to
shower.
The client is observed pacing back and forth in the room. The client is visibly upset and tearful and states, "I
can't live like this anymore. Everything in my life is going wrong." The client is encouraged to use deep
breathing and relaxation techniques to ease anxiety.
The client remains isolated to the room, pacing back and forth. The client rates depression as 6 on a scale of
0-10 and anxiety as 5 on a scale of 0-10.
The client was observed collecting blankets and storing them in the room behind the bed. When
approached, the client became defensive.
The nurse is caring for the client 4 days after admission. For each finding below, click to specify if the finding indicates that the client's status is improving or concerning.
- A. Client ate 80% of the meals and took a shower today.
- B. Client is seen joining group activities in the day room.
- C. Client states, "I feel more energetic today than I have in many months."
- D. Client is seen handing a personal watch and photo album to another client.
- E. Client reports depression 0/10 and states, "I feel a lot better. I think I know what I need to do now."
Correct Answer:
Rationale: Participation in group activities, increased appetite, and performing self-hygiene (eg, showering) indicate an
improvement in the client's status because the client was previously withdrawn with little interest in interacting with others or
performing self-care (eg, declining breakfast tray, body odor).
During the early phase of therapy with antidepressants (eg, selective serotonin reuptake inhibitors [escitalopram]), the risk of
suicide may increase because clients can become more energized as the depression lifts, enabling them to carry out previous
suicide plans. The nurse should find concerning the client's statements about feeling more energized and "knowing what to
do now," which can indicate that the client has determined a plan for suicide and is at peace knowing the plan.
Giving away meaningful possessions (eg, watch, photo album) is concerning for an impending suicide attempt. The nurse
should ask directly about thoughts of suicide.