Nokea
Nurses' Notes
Initial Clinic Visit
1100:
The client has experienced enuresis at night for the past 2 weeks and frequently requests to use the
bathroom while at school. The client was previously toilet trained with no nighttime bed wetting for 6 months;
the client recently relocated to a new home and school where the client lives with parents.
The parent reports that the client has recently demonstrated fatigue, irritability, and multiple behavioral
outbursts that resemble past temper tantrums. The client frequently reports feeling thirsty. No dysuria or
urinary hesitancy is reported.
Weight and height were in the 40th percentiles at the previous visit a year ago. Growth charts today show
the client's weight in the 20th percentile and height in the 40th percentile.
The client appears tired and irritable. Dry mucous membranes are noted with no increased work of
breathing. The lungs are clear to auscultation bilaterally. No cardiac murmur is heard.
The nurse has reviewed the information from the Laboratory Results. Complete the following sentence/sentences by choosing from the list/lists of options. Complete the following sentence by choosing from the lists of options . The client is most likely experiencing---------- and requires ------------- to prevent-------------
- A. Behavior Therapy
- B. Diabetes Mellitus
- C. Urinary Tract Infection
- D. Blood glucose managment
- E. Urosepsis
- F. Hyperglycemia
Correct Answer: B,D,F
Rationale: The client is most likely experiencing diabetes mellitus (DM) and requires blood glucose management to prevent
hyperglycemia.
A urinalysis positive for glucose and ketones are manifestations that should raise suspicion of DM. Ketones are produced
when the body cannot use glucose for energy and breaks down fat stores instead. Ketonuria is a sign of diabetic ketoacidosis
(DKA), a life-threatening complication of DM. Clients with new-onset type 1 DM often present with DKA. Blood glucose
management in those with type 1 DM will require insulin administration.
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History and Physical
Body System
Findings
General
Client reports a 1-week history of general malaise, fever and chills, night sweats, fatigue, and
poor appetite. Client has poorly controlled hypertension, hypercholesterolemia, and mitral
valve prolapse and regurgitation.
Eye, Ear, Nose, and
Throat (EENT)
Poor dental hygiene. Client reports having 2 teeth extracted 3 weeks ago.
Pulmonary
Vital signs are RR 18 and SpO, 96% on room air. Lungs are clear to auscultation bilaterally.
Cardiovascular
Vital signs are T 100.4 F (38 C), P 105, and BP 140/82. Sinus tachycardia with occasional
premature ventricular contractions on cardiac monitor. S1 and S2 heard on auscultation with
loud systolic murmur at the apex. Peripheral pulses 2+; no edema noted.
Integumentary
Small, erythematous macular lesions on both palms. Thin, brown longitudinal lines on several
nail beds.
For each finding below, click to specify if the finding is consistent with the disease process of infective endocarditis, pericarditis, or pneumonia. Each finding may support more than one disease process.
- A. New or worsening cardiac murmurs
- B. Muffled heart sounds on auscultation
- C. Splinter hemorrhages on the nail beds
- D. Presence of flu-like symptoms and fever
- E. Substernal pain that is aggravated by inspiration
Correct Answer:
Rationale: Infective endocarditis occurs when an infectious organism forms a vegetation on a heart valve (interior of the heart). Clients
often have nonspecific symptoms of infection such as fever, flu-like symptoms (myalgia, arthralgia), and malaise.
Vegetation on a heart valve makes the valve dysfunctional, creating a new or worsening cardiac murmur. Pieces of
endocardial vegetation can break off, forming microemboli that travel through the arteries to end-capillaries and block blood
flow (eg, splinter hemorrhages on the nail beds), and cause erythematous macular lesions on the palms or soles (Janeway
lesions).
Acute pericarditis is inflammation of the membranous sac surrounding the exterior of the heart (pericardium), which often
causes an increased fluid in the pericardial cavity (ie, pericardial effusion). If pericardial effusions accumulate rapidly or are
very large, they may compress the heart, altering the mechanics of the cardiac cycle (ie, cardiac tamponade). Clinical
manifestations of pericarditis include muffled heart sounds on auscultation, presence of flu-like symptoms and fever, and
substernal pain that is aggravated by inspiration (ie, pleuritic chest pain). Pericardial friction rub, a superficial scratching or
squeaky sound, may be present, but cardiac murmurs are not present (no valve involvement) and embolic phenomena are
uncommon.
Pneumonia is an infection in the lungs that results in the production of cellular debris and purulent secretions that obstruct the
alveoli and prevent adequate oxygenation. Clinical manifestations include the presence of flu-like symptoms and fever,
pleuritic chest pain, tachycardia, low capillary oxygen saturation (SpO2), crackles, and productive cough with purulent
sputum.
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 two-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 parents 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.
Laboratory Results
Laboratory Test and
Reference Range
1030
Glucose (random)
71-200 mg/dL
(3.9-11.1 mmol/L)
110 mg/dL (6.1 mmol/L)
Sodium
136-145 mEq/L
(136-145 mmol/L)|
133 mEq/L (133 mmol/L)|
Potassium
3.5-5.0 mEq/L
(3.5-5.0 mmol/L)
4.5 mEq/L (4.5 mmol/L)
B-type natriuretic peptide
<100 pg/mL
(<100 ng/L)
640 pg/mL (640 ng/L)
Diagnostic Results
Chest X-ray
1030:Mild cardiomegaly
Echocardiogram
1100:Mild left ventricular hypertrophy with left ventricular ejection fraction of 30%
For each finding below, click to specify if the finding is consistent with the expected action of the medication carvedilol, enalapril, or furosemide. Each finding may support more than one medication.
- A. Decreases heart rate
- B. Increases urinary output
- C. Decreases blood pressure
- D. Increases oxygen saturation
Correct Answer:
Rationale: Pharmacologic management of heart failure (HF) focuses on reducing cardiac workload and improving cardiac output.
• Beta-adrenergic antagonists ("beta blockers") (eg, carvedilol) reduce cardiac workload by inhibiting the action of
catecholamines (eg, epinephrine, norepinephrine) on beta-adrenergic receptors in the heart. Beta blockers decrease
myocardial oxygen demand by decreasing blood pressure and decreasing heart rate.
• Angiotensin-converting enzyme (ACE) inhibitors (eg, enalapril) alter the renin-angiotensin-aldosterone system by
inhibiting conversion of angiotensin I to angiotensin II, thereby preventing the release of aldosterone. Aldosterone, an
adrenal steroid hormone, retains sodium and water in addition to promoting vasoconstriction. By reducing circulating
aldosterone, ACE inhibitors promote vasodilation and as a result decrease blood pressure. ACE inhibitors also
decrease ventricular remodeling, an added benefit for clients with HF.
• Loop diuretics (eg, furosemide) prevent reabsorption of sodium and chloride in the kidneys, which increases urine
output and fluid excretion. Decreases in circulating fluid volume will decrease blood pressure and reduce pulmonary
edema (ie, increase oxygen saturation), as well as decrease cardiac preload.
The nurse is caring for a 64-year-old client.
History and Physical
Body System, Findings
General ,
The client reports a 24-hour history of blurred vision and redness in the left eye with a left-sided headache.
This evening, the client developed acute, severe pain in the left eye accompanied by occasional nausea and
vomiting. The client reports no use of systemic or topical eye medications. Medical history includes
osteoarthritis and hypercholesterolemia.
Eye, Ear, Nose, and Throat (EENT),
The client wears eyeglasses to correct farsighted vision. Right eye: pupil 2 mm and reactive to light,
conjunctiva clear. Left eye: pupil 4 mm and nonreactive to light with red conjunctiva. Bilateral lens opacity is noted.
Pulmonary,
Vital signs are RR 20 and SpO, 96% on room air. The lungs are clear to auscultation bilaterally.
Cardiovascular,
Vital signs are T 99 F (37.2 C), P 88, and BP 140/82.
Psychosocial,
The client reports a great deal of emotional stress following the recent death of the client's spouse that is accompanied by lack of sleep, poor appetite, and a 7.9-lb (3.6-kg) weight loss within the past month. The client takes diphenhydramine for sleep.
Complete the following sentence by choosing from the lists of options. The nurse suspects that the client's current symptoms are due to -------------------------
and that the client is at increased risk for permanent vision loss due to--------------------------
- A. Cataracts
- B. Infection
- C. Retinal detachment
- D. Corneal ulcer
- E. Angle-closure glaucoma
- F. Optic nerve ischemia
Correct Answer: E,F
Rationale: Acute angle-closure glaucoma results from a significant increase in intraocular pressure (IOP) (>50 mm Hg) due to impaired aqueous
humor drainage. In susceptible individuals (eg, those with a narrow anterior chamber angle), dilation of the pupil causes the iris to press
against the lens, preventing flow of aqueous humor through the pupil. This causes the iris to bulge forward, closing the anterior chamber
angle and blocking drainage of aqueous humor through the trabecular meshwork. The rise in IOP leads to immediate optic nerve ischem
potentially resulting in permanent vision loss.
The nurse is caring for a 24-year-old client.
Nurses' Notes
Emergency Department
1300:
The client is brought to the emergency department after a motor vehicle collision in which the driver's side airbag deployed.
The client was driving the vehicle and was not restrained by a seat belt. The client reports shortness of breath and chest
pain on inspiration and expiration.
History and Physical
Body System ,Findings
Neurological,
Awake, alert, and oriented to person; pupils equal, round, and reactive to light and accommodation; client is
agitated and moves all extremities spontaneously but does not follow commands
Integumentary, Superficial lacerations to the face; diffuse bruising noted on upper extremities and chest wall
Pulmonary,
Vital signs: RR 30, SpOz 92% via nonrebreather mask; unilateral chest wall expansion observed on inspiration;
left-sided tracheal deviation noted; breath sounds diminished throughout the right lung field
Cardiovascular,
Vital signs: P 104, BP 90/58; S1 and S2 heard on auscultation; all pulses palpable; no extremity peripheral edema
noted
Psychosocial ,Alcohol odor noted on the client's breath
Diagnostic Results
Chest X-ray
Accumulation of air in the pleural cavity, tracheal deviation to the left. Findings consistent with a tension pneumothorax.
A new chest tube collection device is attached and set to water seal suction. Which of the following observations are expected? Select all
that apply.
- A. A drainage tube coiled on the floor next to the chest tube collection device
- B. Continuous bubbling in the water seal chamber
- C. Occlusive sterile gauze dressing present over the tubing insertion site
- D. The chest tube collection device positioned below the chest tube insertion site
- E. Tidaling in the water seal chamber with inspiration and expiration
Correct Answer: C,D,E
Rationale: Chest tube drainage collection containers must always remain upright and be dependent to (lower than) the client's chest to prevent
gravitational reflux of any secretions back into the pleural cavity (Option 4).
An occlusive sterile gauze dressing should cover the chest tube insertion site. An occlusive dressing (eg, petroleum gauze) protects
against infection and prevents atmospheric air from entering the pleural space if a leak is present (Option 3).
The water level in the water seal chamber rises with inspiration and falls with expiration due to changes in intrapleural pressure, a
process known as tidaling. This movement indicates negative pressure is being maintained. Tidaling is not expected when the device is
connected to suction; therefore, the nurse should disconnect suction to assess tidaling (Option 5).
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 two-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 parents 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.
Laboratory Results
Laboratory Test and
Reference Range
1030
Glucose (random)
71-200 mg/dL
(3.9-11.1 mmol/L)
110 mg/dL (6.1 mmol/L)
Sodium
136-145 mEq/L
(136-145 mmol/L)|
133 mEq/L (133 mmol/L)|
Potassium
3.5-5.0 mEq/L
(3.5-5.0 mmol/L)
4.5 mEq/L (4.5 mmol/L)
B-type natriuretic peptide
<100 pg/mL
(<100 ng/L)
640 pg/mL (640 ng/L)
Diagnostic Results
Chest X-ray
1030:Mild cardiomegaly
Echocardiogram
1100:Mild left ventricular hypertrophy with left ventricular ejection fraction of 30%
For each potential intervention, click to specify if the intervention is expected or not expected for the care of the client.
- A. Daily weights
- B. IV furosemide
- C. Fluid restriction
- D. Supplemental oxygen
- E. Antihypertensive medications
- F. Nebulized albuterol breathing treatments
Correct Answer:
Rationale: Expected interventions for acute decompensated heart failure (HF) focus on reducing cardiac workload and improving
oxygenation. These include:
• Daily weights should be performed to monitor fluid volume status and guide treatment. Ideally, daily weights should be
performed at the same time of day, on the same scale, and with the client wearing the same amount of clothing.
• Diuretics (eg, furosemide) prevent reabsorption of sodium and chloride in the kidneys, which increases fluid excretion in
urine and decreases preload. Diuretics provide symptomatic relief by reducing pulmonary congestion and peripheral
edema. These are the cornerstone of therapy and often a priority after oxygen therapy.
• Fluid restriction is indicated to decrease circulating fluid volume and prevent excess strain on the heart.
• Supplemental oxygen should be administered to improve oxygen delivery in clients with HF due to impaired gas
exchange from pulmonary edema.
• Antihypertensive medications reduce cardiac workload and improve contractility by lowering blood pressure (ie,
afterload).
Nebulized albuterol is a bronchodilator administered to improve oxygenation in clients with reactive airway disease (eg.
asthma, chronic obstructive pulmonary disease). Bronchodilators will not improve oxygenation in clients with pulmonary
edema and are not expected for treatment of HF.