Nokea
The nurse has reviewed the information from the Laboratory Results. Which of the following conditions should the nurse suspect? Select all that apply.
- A. Attention deficit hyperactivity disorder
- B. Major depressive disorder
- C. Posttraumatic stress disorder
- D. Schizophrenia
- E. Substance use disorder
Correct Answer: B,E
Rationale: Major depressive disorder (MDD) is characterized by a persistent (duration ≥2 weeks) depression in mood (eg, sadness,
social withdrawal) that interferes with daily life. This client has several clinical manifestations of MDD, including loss of interest
in daily activities, significant change in appetite or weight, persistent feelings of worthlessness, recurrent thoughts of self-harm,
inattention, and fatigue. MDD is a significant risk factor for suicide
Substance use disorder is the recurrent use of alcohol and/or recreational drugs that results in interpersonal dysfunction,
impaired control, and physical effects (eg, withdrawal). This client's urine drug screen is positive for cocaine and marijuana
Therefore, the nurse should further investigate the client's substance use (eg, amount, frequency, route of administration, date
of last use, perceived benefits, negative consequences)
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The client returns to the clinic 6 months after starting behavioral therapy. Which statement by the parent indicates a need for further therapy?
- A. My child will eat but only if I cook the same meal every day.
- B. My child will make only brief periods of eye contact with the teacher.
- C. My child will occasionally play with other children at the park.
- D. My child will squeeze a soft toy instead of banging the head.
Correct Answer: A
Rationale: Early childhood intervention programs (eg, behavioral therapy) are a critical component for clients with autism spectrum
disorder and can have positive long-term effects on presenting symptoms and social skills. Therapy helps increase
communication and language skills; improve focus, social skills, memory, and academic functioning; and decrease problematic
behaviors through positive reinforcement and other behavioral approaches
When evaluating the outcomes of therapy, the nurse should recognize that clients who demonstrate narrowed, restricted
interests (eg, eating the same foods) indicate a need for additional therapy
For each potential prescription, click to specify whether the prescription is expected or not expected for the care of the client.
- A. Administer IV antibiotics
- B. Prepare client for echocardiography
- C. Initiate low-flow supplemental oxygen
- D. Gather supplies for pericardiocentesis
- E. Place peripherally inserted central catheter (PICC)
- F. Collect a blood specimen for culture and sensitivity
Correct Answer:
Rationale: Expected prescriptions for clients with suspected infective endocarditis (IE) include:
• Administering IV antibiotics to kill the infectious pathogen
• Preparing the client for echocardiography to identify valvular dysfunction, chamber enlargement, and vegetations
• Placing a peripherally inserted central catheter for long-term IV antibiotic therapy
• Collecting a blood specimen for culture and sensitivity to identify the infectious pathogen
Initiating low-flow supplemental oxygen is not expected because the client is not exhibiting signs of respiratory distress.
Pericardiocentesis is performed to remove excess fluid from the pericardial cavity and prevent progression to cardiac
tamponade. Pericardial effusions are not commonly expected with IE. Furthermore, this client is not exhibiting signs of
pericardial effusion (eg, muffled heart sounds, substernal pain). Therefore, gathering supplies for pericardiocentesis is not
expected.
The nurse has reviewed the information from the Diagnostic Results and Nurses' Notes. For each finding, click to specify whether the finding indicates that the client's status has not changed or has declined
- A. BP 102/70
- B. T 100.4 F (38 C)
- C. Peripheral pulses 1+
- D. Shortness of breath when recumbent
- E. Scattered crackles on lung auscultation
Correct Answer:
Rationale: Infective endocarditis (E) requires long-term antibiotic therapy (ie, 4-6 weeks). Fever (eg, T 100.4 F [38 C]) can persist for
several days despite appropriate antibiotic therapy.
In addition to the risk for systemic embolism (eg, stroke), clients with IE are at risk for heart failure if the involved valve
becomes dysfunctional. Decreased capillary oxygen saturation, shortness of breath when recumbent, and scattered
crackles on lung auscultation indicate fluid backup in the lungs. In addition, borderline low blood pressure (compared to
uncontrolled high blood pressure at admission) and decreased peripheral pulses (1+ vs 2+ on admission) indicate decreased
cardiac output and are concerning for heart failure.
The nurse is reinforcing home care teaching to the client. Which statement by the client requires the nurse to provide further instruction?
- A. I should ask family members to bring prepared meals to me." (13%)
- B. "I should eat small, frequent meals every 2-3 hours." (16%)
- C. I will avoid drinking fluids with my meals." (30%)
- D. I will eat hot soups to settle my stomach." (38%)
Correct Answer: D
Rationale: Self-management of hyperemesis gravidarum is an important component of discharge teaching. The goal of home care is to prevent nausea
and vomiting and promote appropriate nutritional intake and weight gain, which can support a healthy pregnancy.
Some triggers for nausea and vomiting include an empty or overly full stomach, strong food odors, and greasy or fatty foods. It is often
recommended that clients eat cold or bland foods due to the increased aromas associated with hot foods. Therefore, the nurse should
provide further teaching to this client who plans to eat hot soup because this may precipitate nausea (Option 4). The nurse can suggest
eating foods such as toast, crackers, nuts, or cold cereal.
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.