The nurse has reviewed the information from the Nurses' Note...

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 nurse has reviewed the information from the Nurses' Notes. For each potential intervention, click to specify if the intervention is anticipated or not anticipated for the care of the client.

A. Encourage the client to play with others in the playroom
B. Follow a structured routine and schedule for providing care
C. Consistently assign the same nursing staff to the client when possible
D. Assign the client to a shared room with another client who has autism
E. Use direct eve contact and therapeutic touch when talking to the client

Correct Answer:

Rationale: Clients with autism spectrum disorder (ASD) are often hesitant about changes and have a heightened behavioral response
when placed in an unfamiliar environment (eg, hospital). The nurse should consider the client's unique needs when planning
care. Anticipated interventions for decreasing anxiety and enhancing cooperation when caring for clients with ASD include:
• Following a structured routine and schedule for providing care to reduce distress and promote normalcy
• Consistently assigning the same nursing staff to the client when possible to facilitate trust and communication
because clients with ASD often have difficulties adjusting to changes in their surroundings
• Establishing a method for communication that is brief, concrete, and developmentally appropriate (eg, picture boards) to
decrease frustration due to impaired verbal and nonverbal communication
Clients with ASD are hypersensitive to environmental factors and may become distressed and overstimulated by noise and
activity. Therefore, encouraging the client to play with others in the playroom and assigning the client to a shared room
with another client who has autism are not anticipated
Clients with ASD may be fearful of, or hypersensitive to, touch and direct eye contact. The nurse should use other means of
developing trust (eg, being consistent, conveying acceptance, using positive reinforcement).

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%

The nurse suspects the client is experiencing acute decompensated heart failure. Which of the following findings are consistent with this condition? Select all that apply.

A. Crackles with auscultation
B. Decreased capillary oxygen saturation
C. Elevated b-type natriuretic peptide
D. Left ventricular ejection fraction 30%
E. Lower extremity pitting edema

Correct Answer: A,B,C,D,E

Rationale: The findings all support the diagnosis of acute decompensated heart failure (ADHF):

Crackles with auscultation: Indicative of pulmonary congestion due to fluid overload.

Decreased capillary oxygen saturation: Reflects impaired gas exchange from fluid in the lungs.

Elevated B-type natriuretic peptide (BNP): A level of 640 pg/mL is significantly elevated; BNP is released when the ventricles are stretched due to increased fluid volume.

Left ventricular ejection fraction of 30%: Normal is 55–70%. This reduced EF confirms systolic dysfunction, common in ADHF.

Lower extremity pitting edema: A classic sign of volume overload in right-sided or total heart failure.

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.

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 68-year-old client in the emergency department.
Nurses' Notes,

Emergency Department
1020:
The client reports shortness of breath, a 2-lb weight gain over the past week, and lower extremity swelling. The client
reports slight chest discomfort during activity that is relieved with rest. Medical history is significant for hypertension.
myocardial infarction, heart failure, coronary artery disease, and chronic stable angina. Current medications include
metoprolol, furosemide, potassium chloride, lisinopril, and aspirin. The client takes all medications as prescribed except
one; he states, "I do not take that water pill because I got tired of having to go to the bathroom all the time."
S1 and S2 are present; a prominent S3 is heard. Respirations are labored with inspiratory crackles in the middle and at the
base of the lungs. The abdomen is soft and nontender with normoactive bowel sounds. There is 3+ pitting edema in the
bilateral lower extremities.

Vital Signs,
1020
T ,98.8 F (37.1 C)
P, 60
RR, 24
BP, 168/96
SpO2, 90% on room air

Laboratory Test and Reference Range, 1030
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),
6.5 mEq/L
(6.5 mmol/L)
BUN
10-20 mg/dL
(3.6-7.1 mmol/L),
22 mg/dL
(7.85 mmol/L)
Creatinine
Male: 0.6-1.3 mg/dL
(53-114.9 umol/L),
1.5 mg/dL
(132.6 umol/L)
Female: 0.5-1.1 mg/dL
(44.2-97.2 umol/L)

The nurse has reviewed the information from the Laboratory Results. Complete the following sentence/sentences by choosing from the list/lists of options.The nurse should prioritize interventions to treat ------------ due to the risk of ---------------------.

A. Hyperkalemia
B. Dysrhythmias
C. Elevated BUN
D. Seizures
E. Hyponatremia
F. Acute kidney injury

Correct Answer: A,B

Rationale: The client's laboratory results show hyperkalemia (ie, high potassium) and decreased kidney function, seen as elevated BUN and creatinine.
The kidneys balance potassium levels by eliminating excess potassium through urine. Clients with heart failure (HF) are at an increased risk fo
hyperkalemia due to poor kidney perfusion from decreased cardiac output and medication adverse effects. This client's decreased kidney
function and home medications, including lisinopril (ACE inhibitor) and supplemental potassium chloride, all increase the risk of hyperkalemia.
Because potassium is responsible for myocardial cell repolarization, hyper- or hypokalemia may lead to life-threatening dysrhythmias.
Therefore, the nurse should prioritize interventions to treat hyperkalemia due to the risk of dysrhythmias.

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

Which of the following information about the client is important to report to the health care provider? Select all that apply.

A. Blood pressure
B. Fetal movement
C. Nausea and vomiting
D. Right-sided abdominal pain
E. Weight change

Correct Answer: A,C,E

Rationale: The nurse caring for pregnant clients must distinguish pregnancy-related adaptations and discomforts from potential complications. It is
important to report the following client findings to the health care provider:
• Abnormal vital signs (eg, low blood pressure): Hypotension and tachycardia may be symptoms of hypovolemia due to decreased oral
intake and vomiting (ie, dehydration)
• Severe nausea and vomiting: Although these findings are common discomforts associated with early pregnancy, concern is warranted
if they are persistent; prevent oral intake; and cause significant weight loss, dehydration, and hypovolemia
• Significant weight change (eg, weight loss of 25% of prepregnancy weight): Weight loss is generally not recommended during
pregnancy and may indicate a medical condition (eg, nutritional deficiency). Normal changes in weight during pregnancy include gaining
1-4 Ib (0.5-1.8 kg) during the first trimester and approximately 1 lb (0.5 kg) per week thereafter

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