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

The nurse in the emergency department is caring for a 62-year-old client.
History and Physical
Neurological
The client is alert and oriented to time, place, person, and situation; the client reports sudden-onset right-sided facial drooping, speech is slurred; positive right-sided arm drift is seen
Eye, Ear, Nose, and Throat (EENT)
Bilateral pupils are equal, round, and reactive to light and accommodation

Pulmonary
Vital signs: RR 16, SpO, 95% on room air, lung sounds are clear bilaterally

Cardiovascular
Vital signs: T 99 F (37.2 C), P 86, BP 166/90; S1 and S2 are heard on auscultation; no murmurs are noted; the client has a history of hypertension

Musculoskeletal
Right-sided lower extremity weakness is seen

Endocrine
The client has diabetes mellitus

Psychosocial
The client reports drinking one glass of wine each evening with dinner, no tobacco use, and a history of major depression; the client takes sertraline.

Laboratory Results
During Admission
Blood Chemistry.
Glucose: 72 mg/dL (4.0 mmol/L)
Sodium: 133 mEq/L (133 mEq/L)
Chloride: 101 mEq/L (101 mmol/L)
Potassium: 3.7 mEq/L (3.7 mmol/L)

Laboratory Test and Reference Range
Blood Chemistry.
Glucose 74-106 mg/dL (4.1-5.9 mmol/L)
Sodium 136-145 mEq/L (136-145 mmol/L)
Chloride 98-106 mEq/L(98-106 mmol/L)
Potassium 3.5-5.0 mEq/L (3.5-5.0 mmol/L

Diagnostic Results
Admission
CT scan of the head without contrast
1830:
No areas of hemorrhage are noted

Nurses’ notes
Intensive Care Unit
2100:
Tissue plasminogen activator infusion is complete.
2330:
The client suddenly has become combative and confused and is disoriented to person, place, and time. The client vomited once forcefully. Neurologic assessment shows confusion and right-sided weakness.
Vital signs: T 100 F (37.8 C), P 105, RR 18, BP 188/94, SpO2 96% on room air.

The nurse has reviewed the information from the Nurses' Notes. Which of the following is the priority action?

A. Administer PRN acetaminophen and observe
B. Give PRN blood pressure medication and observe
C. Prepare the client for repeat CT scan of the head
D. Request a prescription for restraints

Correct Answer: C

Rationale: The client's sudden change in mental status (combative, confused, disoriented) and vomiting after tissue plasminogen activator (tPA) infusion suggest a possible intracranial hemorrhage, a known complication of tPA. A repeat CT scan is the priority to assess for this life-threatening condition.

The nurse in the surgical unit is caring for a 57-year-old client who underwent an abdominal hysterectomy.
Progress Notes
1 Day Postoperative
0800:
The client underwent total abdominal hysterectomy with bilateral oophorectomy and tumor debulking 1 day ago for treatment of ovarian cancer. She has had four episodes of vomiting with bilious emesis over the past 12 hours, which have continued despite V antiemetic administration. The client has been receiving V broad-spectrum antibiotics since the procedure. The skin is warm. A low transverse abdominal incision is present; staples are clean and dry. Chest expansion is symmetric; respirations are unlabored: diminished breath sounds are auscultated in bilateral lower lobes. Radial pulses 2+ bilaterally, capillary refill <3 seconds in all four extremities; no peripheral edema is noted. The client reports frequent hot flashes occurring roughly every hour, starting last night. The abdomen is markedly distended and tender to palpation. Bowel sounds are absent in all four quadrants; the client reports no flatus. Urine is clear yellow with moderate output. The client reports incontinence with coughing or during episodes of vomiting.

The nurse is assisting the registered nurse with developing the plan of care. For each potential intervention, click to specify the intervention is anticipated or unanticipated for the care of the client.

A. Insert a rectal tube
B. Advance to a regular diet
C. Place the client on strict bed rest
D. Measure abdominal girth frequently
E. Request a nonopioid pain medication
F. Apply a cold pack to the abdomen for pain

Correct Answer: A: Anticipated, B: Unanticipated, C: Unanticipated, D: Anticipated, E: Anticipated, F: Unanticipated

Rationale: A rectal tube may help decompress the bowel in ileus. Advancing to a regular diet is contraindicated until bowel function returns. Strict bed rest is not necessary; ambulation is encouraged. Measuring abdominal girth monitors distension. Nonopioid pain medication is appropriate for pain management. Cold packs are not standard for abdominal pain in ileus and may not be effective.

The nurse is caring for a 6-hour-old newborn.
Nurses' Notes
Emergency Department
A newborn is brought to the emergency department due to coughing and difficulty feeding. The client was born at home 6 hours ago via spontaneous vaginal birth. With each attempt to breastfeed, the client coughs, vomits, and "turns blue." The mother did not receive prenatal care. She reports a history of opioid use disorder but reports no opioid use during pregnancy.
Vital signs: T 98.6 F (37 C), P 120, RR 50, and SpO, 95% on room air. Abdominal distension is present. Ballard scoring estimates the client at 37 weeks gestation. Weight and length are consistent with the 25th and 50th percentiles for estimated age, respectively.
1 Hour Later
After attempting a bottle feed with 10 mL of formula, the client has a coughing episode, and there is formula mixed with saliva in the mouth. Coarse breath sounds are noted bilaterally with intercostal retractions. S1 and S2 are present with no murmurs. Neurologic examination shows normal neuromuscular findings.
A nasogastric tube insertion is attempted per prescription by the health care provider, and resistance is met at 10 cm of insertion.

The nurse recognizes that the client is most likely experiencing a tracheoesophageal fistula with esophageal atresia and will require interventions to prevent ___ and ___

A. Hernia
B. Dehydration
C. Aspiration pneumonia
D. Necrotizing enterocolitis

Correct Answer: B,C

Rationale: Tracheoesophageal fistula can lead to aspiration pneumonia due to food entering the lungs and dehydration from inability to feed properly. These are the most immediate risks requiring intervention.

The nurse is caring for a 12-month-old male client.
History and Physical
Body System
General
The client is brought to the emergency department by the parents due to increased leg bruising and left knee swelling for 1 day; the parents report that the client seems more tired and less playful; both parents and the sister are healthy, but a maternal uncle died at age 7 after mild head trauma.

Integumentary
Good hygiene; no abrasions; no burns; bilateral scattered lower extremity bruising

Eye, Ear, Nose, and Throat (EENT)
The parents report that the client's gums have been bleeding when chewing on crackers

Pulmonary
Vital signs: RR 38, SpO 100% on room air, upper respiratory infection 3 weeks ago that completely resolved after 4 days.

Cardiovascular
Vital signs: T 98.7 F (37.1 C), P 136

Musculoskeletal
Left knee redness and swelling with limited range of motion; the client can bear weight on both lower extremities; the parents state the child has recently started learning to walk by holding onto furniture and sometimes falls

Genitourinary
The parents state that urine output has been normal; urine is clear and pale yellow; the penis is uncircumcised

Psychosocial
The client is cooperative during examination; the client appears appropriately dressed for the season and weather; the mother says the child has no interest in toilet-training.

Laboratory Results.
Laboratory Test and Reference Range
Hematology.

Hematocrit
1-6 years: 39% (0.39)
30%-40%:
(0.30-0.40)

WBC
<_ 2 years: 8000/mm3 (8.0 × 10%/L)
6200-17,000/mm3
(6.2-17.0 × 10°/L)
Platelets
150,000-400,000/mm3: 163,000/mm3 (163 × 10°/L)
(150-400 × 10°/L)

aPTT (Activated partial thromboplastin time)
30-40 sec: 60 sec

PT
11-12.5 sec: 12 sec

Factor VIII
55%-145%: 6%

Factor IX
60%-140%: 100%

For each potential intervention, click to specify if the intervention anticipated or unanticipated for the care of the client.

A. Monitoring a platelet transfusion
B. Providing a soft-bristled toothbrush
C. Ensuring fall precautions are in place
D. Using a small-gauge needle for injections
E. Encouraging rest, ice, compression, and elevation
F. Reinforcing teaching about lifelong factor replacement

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

Rationale: B: Anticipated - A soft-bristled toothbrush reduces gum bleeding risk in hemophilia. C: Anticipated - Fall precautions prevent injuries that could cause bleeding. D: Anticipated - Small-gauge needles minimize tissue trauma. E: Anticipated - RICE is used for joint bleeding in hemophilia. F: Anticipated - Lifelong factor replacement is standard for hemophilia management. A: Unanticipated - Platelet transfusion is not indicated as platelet count is normal.

Which 3 additional findings or diagnostic results are most important to plan care for this client?

A. Blood alcohol level
B. Capillary blood glucose level
C. CT scan of the head
D. Electroencephalography
E. Standardized stroke assessment

Correct Answer: B, C, E

Rationale: A CT scan (C) is critical to diagnose stroke type. A standardized stroke assessment (E) evaluates severity and guides treatment. Capillary glucose (B) ensures hypoglycemia is not contributing to symptoms. Blood alcohol level (A) is less relevant with minimal alcohol history. EEG (D) is not urgent for suspected stroke.

The nurse is caring for a 25-year-old female client.
History and Physical
Body System
General
Client reports jitteriness, anxiety, and palpitations for the past 2 months. Fine hand tremor is noted. Client reports insomnia for approximately 1 week.
Integumentary
Client is diaphoretic.
Eye, Ear, Nose, andThroat (EENT)
Exophthalmos is noted. Goiter is present.
Gastrointestinal
Client reports 10 lb (4.5 kg) weight loss over the past month. Bowel sounds are normoactive. Client reports diarrhea for the past few days.
Reproductive
Last menstrual period was 3 months ago.
Vital Signs
T 99.2 F (37.3 C)
P 164
RR 22
BP 156/92

The client is most likely experiencing.......... and requires intervention to prevent............

A. Hypothyroidism
B. Hyperthyroidism
C. Addison disease
D. Addisonian crisis
E. Myxedema
F. Acute thyrotoxicosis

Correct Answer: B,F

Rationale: The client's symptoms (tachycardia, weight loss, exophthalmos, etc.) indicate hyperthyroidism, and intervention is needed to prevent acute thyrotoxicosis, a life-threatening complication.