The nurse has reviewed the information from the Laboratory R...

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.Three days later, the school nurse is called to the play area because the client is diaphoretic and becomes unconscious. The school nurse notices the clients medical alert bracelet and obtains a blood glucose level. Which action should the school nurse take after reading the blood glucose level?

A. Administer subcutaneous glucagon
B. Administer subcutaneous regular insulin
C. Encourage the client to take sips of an electrolyte drink
D. Provide the client with a snack containing 15 g of simple carbohydrates

Correct Answer: A

Rationale: Rapid growth and unpredictable eating patterns place a child with diabetes mellitus at high risk for hypoglycemia.
Hypoglycemia can occur rapidly and can be life-threatening. Clinical manifestations primarily result from lack of glucose to the
brain (and other vital organs) followed by rapid activation of the sympathetic nervous system:
• Pallor and diaphoresis
• Tremors
• Palpitations and tachycardia
• Altered mental status, irritability, slurred speech, confusion
• Dizziness
If hypoglycemia is suspected, the nurse should immediately obtain a blood glucose level. Clients with hypoglycemia who are
unconscious cannot tolerate oral carbohydrates. Therefore, the nurse should rapidly administer glucagon by injection (eg.
subcutaneous, IM) or apply a glucose paste to the gums. Glucagon increases blood glucose levels by rapidly converting
stored glycogen in the liver into glucose, a process known as glycogenolysis

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
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.

Nurses Notes
Emergency Department
0900:
The client has new-onset tremors, extreme restlessness, nausea, and anxiety. The client recently had a back
injury and was prescribed tramadol. The client also takes sertraline for major depression. On examination,
the client is flushed and diaphoretic. The client's voice is tremulous. Mild rigidity and tremors are noted in the
lower extremities. Deep tendon reflexes are 3+. Pupillary dilation and ocular clonus are present.
Vital Signs
0900
T
100.9 F (38.3 C)
P
125
RR
20
BP
160/100
Sp02
99% on room air
Laboratory Results
Laboratory Test and Reference Range
0900
TSH
0.3-5 uU/mL
(0.3-5 mU/L)
2 pU/mL
(2 mU/L)
WBC
5000-10,000/mm3
(5.0-10.0 × 10%/L)
7800/mm3
(7.8 × 10%L)

The nurse is caring for a 42-year-old client in the emergency department. The nurse is reviewing the collected client data to assist with preparing the client's plan of care. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to measure the client's progress.

A. Administer phenytoin, Discontinue sertraline, Administer methimazole, Administer a benzodiazepine, Prepare to administer radioactive iodine
B. Panic attack, Hyperthyroidism, Serotonin syndrome, Neuroleptic malignant syndrome
C. Clonus, TSH level, WBC count, Temperature, Feelings of impending doom

Correct Answer:

Rationale: Serotonin syndrome (ie, serotonin toxicity) is a life-threatening condition caused by excess serotonin in the central nervous
system. Tramadol is an analgesic medication with serotonergic activity that can lead to serotonin syndrome when taken with a
selective serotonin reuptake inhibitor (eg, sertraline).
Clinical manifestations include mental status changes (eg, anxiety, restlessness, agitation), autonomic dysregulation (eg,
diaphoresis, tachycardia, hypertension, hyperthermia), and neuromuscular hyperactivity. Treatment involves discontinuing all
serotonergic medications (eg, sertraline, tramadol) and administering a benzodiazepine to improve agitation and
decrease muscle contraction (eg, clonus), which reduces temperature.

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.

Complete the following sentence/sentences by choosing from the list of options. The nurse recognizes that the client is most likely experiencing ----------interventions to prevent ---------

A. Pleural effusion
B. Systemic emboli
C. Cardiac tamponade
D. pneumonia
E. pericarditis
F. Infective endocarditis

Correct Answer: F,B

Rationale: The nurse recognizes that the client is most likely experiencing infective endocarditis (lE) and should prioritize interventions
to prevent systemic emboli.
The client is most likely experiencing IE based on the history of a recent dental procedure and clinical findings of infection (eg,
fever, flu-like symptoms), microemboli (eg, splinter hemorrhages, Janeway lesions), and cardiac murmur. In addition to
microemboli, larger pieces of vegetation can break off the heart valve and embolize to various organs, causing life-threatening
complications (eg, stroke, spleen/kidney infarction).

History and Physical
Body System, Finding
General,
Client is brought to the emergency department due to nausea, vomiting, and abdominal pain that began 24 hr
ago. Client has type 1 diabetes mellitus and usually takes insulin. Parents state that the client was at an
overnight camp for the past 4 days and are unsure of how much insulin the client has been taking.
Neurological,
Client is lethargic but arousable to voice. The pupils are equal, round, and reactive to light and accommodation.
Integumentary,
Mucous membranes are dry, skin turgor is poor.
Pulmonary,
Vital signs are RR 36 and SpOz 95% on room air. Lung sounds are clear to auscultation. Deep respirations and a
fruity odor on the breath are noted.
Cardiovascular,
Vital signs are T 98.4 F (36.9 C), P 110, and BP 98/58. Pulses are 3+ on all extremities, and capillary refill time is
4 sec.
Gastrointestinal Normoactive bowel sounds are heard in all 4 quadrants; the abdomen is nontender.
Genitourinary,
Client voided dark yellow urine.
Endocrine,
Client is prescribed levothyroxine daily for hypothyroidism and has missed one dose of levothyroxine.
Psychosocial,
Parents state that the client has been sad and slightly withdrawn for the past 2 weeks after ending a romantic relationship.

Select 4 clinical findings that require immediate follow-up.

A. nausea, vomiting, and abdominal pain
B. lethargic
C. Mucous membranes are dry, skin turgor is poor.
D. missed one dose of levothyroxine
E. capillary refil time is 4 sec.

Correct Answer: A,B,C,E

Rationale: Type 1 diabetes mellitus is an endocrine disorder characterized by the absence of insulin production in the pancreas. Glucose requires insulin
to be transported from the extracellular space into the cell. Without insulin, glucose continues to circulate in the extracellular space, causing
serum hyperglycemia and intracellular glucose starvation that can lead to diabetic ketoacidosis (DKA).
In DKA, the body breaks down fat for energy (ie, ketosis). This leads to high levels of ketones in the blood, which can cause life-threatening
metabolic acidosis. Clinical findings concerning for DKA require immediate follow-up and include:
• Nausea, vomiting, and abdominal pain—a common presentation of DKA (especially in children) that can be related to delayed gastric
emptying and/or ileus from electrolyte abnormalities and metabolic acidosis
• Neurologic symptoms (eg, lethargy, obtundation) due to progressive hyperglycemia and acidosis
• Signs of dehydration (eg, dry mucous membranes, prolonged P3 sec] capillary refill time) due to osmotic water loss caused by
glucose in the urine

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