Nokea
The nurse assesses a client with petechiae and ecchymosis scattered across the arms and legs. Which laboratory result should the nurse review?
- A. Hemoglobin levels.
- B. White blood cell count.
- C. Red blood cell count.
- D. Platelet count.
Correct Answer: D
Rationale: Platelet count is crucial in assessing for thrombocytopenia, which can lead to increased bleeding and bruising, including petechiae and ecchymosis.
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History and Physical Nurses' Notes
Flow Sheet
A 59-year-old male client presents to the clinic reporting pain in the right great toe. The client says that the pain feels like it is another attack of gout, which he has had on 2 other occasions in the last 4 months.
The client tells the nurses that the pain started about 9 days ago in the evening and that it got very painful and swollen shortly thereafter. In the past, the gout attacks have resolved without treatment after about 5 days, but the client reports that his condition has not
Which finding(s) in the client's health record should the nurse recognize places the client at a greater risk of developing gout? Select all that apply.
- A. Obesity
- B. Hypertension
- C. Drinks beer nightly
- D. Daily aspirin
- E. Type 2 diabetes mellitus
- F. Sleep apnea
- G. Ibuprofen for pain
Correct Answer: A,B,C,D,E,F
Rationale: Obesity, hypertension, alcohol consumption (especially beer), low-dose aspirin, type 2 diabetes mellitus, and sleep apnea are all associated with increased uric acid levels or decreased excretion, contributing to gout risk. Ibuprofen, smoking status, and osteoarthritis do not directly increase gout risk.
Which findings during the admission assessment should the nurse document that are related to a client diagnosed with Cushing's syndrome?
- A. Husky voice and troubled by hoarseness.
- B. Central type obesity, with thin extremities.
- C. Warm, soft, moist, salmon colored skin.
- D. Visible swelling of the neck, with no pain.
Correct Answer: B
Rationale: Central type obesity with thin extremities is a classic manifestation of Cushing's syndrome due to excess cortisol, causing fat accumulation in the trunk and muscle wasting in the extremities.
A college student comes to the school's health clinic troubled by urinary frequency and burning with right lower back pain. Which intervention should the nurse implement first?
- A. Palpate the right flank for tenderness.
- B. Test the urine for the presence of hematuria.
- C. Evaluate the urine for a strong odor.
- D. Measure the temperature and pulse rate.
Correct Answer: D
Rationale: Measuring temperature and pulse rate is important to identify signs of systemic infection or inflammation contributing to the client's symptoms.
The nurse is assessing a client who has herpes zoster. Which question will allow the nurse to gather further information about this condition?
- A. Have the antifungal creams been effective?
- B. Do your family members share combs and brushes?
- C. Do you have any dry patches on your feet and hands?
- D. Has everyone at home already had varicella?
Correct Answer: D
Rationale: Asking whether everyone at home has had varicella is important, as herpes zoster can transmit the varicella-zoster virus to non-immune individuals, causing chickenpox.
Nurses' Notes
A 34-year-old male client presents to the emergency department (ED) for an acute asthma attack which began after jogging through a local park. The client is able to answer questions, pausing every few words to catch his breath. The client reports using a rescue Inhaler three times, but he just couldn't catch his breath. The client reports that symptoms seem worse when outdoors and when exercising and that episodes like this make him extremely nervous. The client reports that it has been a couple of months since he had an asthma attack, and he came to the ED today because he noticed that his inhaler was expired and was worried the medication was not working.
Initial Assessment
Temperature 98.9° F (37.1° C)
Heart rate 112 beats/minute
Respirations 28 breaths/minute
Blood pressure 130/86 mm Hg
Oxygen saturation 88% on room air
Lung sounds reveal expiratory wheezes
Capillary refill time 2 seconds
Complete the following sentences by choosing from the lists of corresponding options. Based on history and assessment data, the nurse should prioritize [condition] as the priority problem for this client, as evidenced by the client's statement, [statement].
- A. chronic bronchitis
- B. anxiety disorder
- C. exercise-induced bronchospasm
- D. impaired gas exchange
- E. cardiovascular disease
- F. respiratory infection
Correct Answer: D
Rationale: The client's difficulty breathing, need to pause to catch breath, ineffective rescue inhaler, and oxygen saturation of 88% indicate impaired gas exchange, requiring immediate intervention to improve respiratory function.