The nurse has reviewed the information from the Progress Not...

The nurse has reviewed the information from the Progress Notes. Which of the following statements by the nurse is appropriate? Select all that apply.

A. Avoid carbohydrates as much as possible during pregnancy.
B. Begin a sodium-restricted diet to prevent gestational hypertension.
C. Consume nutrient-dense foods with each meal.
D. Engage in moderate exercise such as walking or yoga for 30 minutes daily.
E. Increase consumption of iron-rich foods such as meat.

Correct Answer: C,D,E

Rationale: Nutrient-dense foods, moderate exercise, and iron-rich foods are appropriate. Avoiding carbohydrates or sodium restriction is not recommended without specific indications.

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

For each potential prescription, click to specify whether the prescription is anticipated or not anticipated at this time.

A. Administer propranolol
B. Administer methimazole
C. Perform a pregnancy test
D. Maintain a high-calorie diet
E. Offer moisturizing eye drops
F. Maintain continuous cardiac monitoring
G. Administer thyroid hormone replacement

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

Rationale: A: Propranolol is anticipated to manage tachycardia and palpitations. B: Methimazole is anticipated to treat hyperthyroidism by reducing thyroid hormone production. C: A pregnancy test is anticipated due to the absence of menstruation for 3 months, as pregnancy can affect treatment choices. D: A high-calorie diet is anticipated to address weight loss and increased metabolism. E: Moisturizing eye drops are anticipated for exophthalmos-related eye dryness. F: Continuous cardiac monitoring is anticipated due to the high pulse rate (164). G: Thyroid hormone replacement is not anticipated, as the client has hyperthyroidism, not hypothyroidism.

The nurse in the emergency department is caring for a 62-year-old client.
Progress Notes
Emergency Department
0900: The client is brought to the emergency department by a family member after being found confused and lethargic. On arrival, the client is obtunded and does not respond to verbal stimuli.
Medical history includes major depressive disorder and chronic neck and back pain after a motor vehicle collision 2 years ago. The family member states that the client takes multiple medications but does not know which kind. The client was divorced a few months ago.
Physical examination shows 1-mm pupils, shallow breathing, and reduced bowel sounds. Fingerstick blood glucose is 78 mg/dL (4.3 mmol/L). ECG reveals normal sinus rhythm. Breath alcohol test is negative.
Vital signs: T 98.1 F (36.7 C), P 62, RR 8, BP 80/40, SpO, 94% on room air.
1800:
The client is awake, alert, and oriented to person, place, time, and situation. The client is experiencing severe withdrawal symptoms and is admitted for supervised detoxification.

Laboratory Results
Urine Drug Screen
On admission
Cocaine- Negative
Opioids- Positive
Amphetamines- Negative
Marijuana- Positive
Phencyclidine-Negative
Benzodiazepines- Negative
Barbiturates- Negative
Laboratory Test and Reference Range
Cocaine- Negative
Opioids- Negative
Amphetamines- Negative
Marijuana- Negative
Phencyclidine- Negative
Benzodiazepines- Negative
Barbiturates- Negative

The nurse is evaluating teaching for the client who is newly prescribed methadone for opioid use disorder. Which of the following client statements indicate that the teaching has been effective? Select all that apply.

A. I can take an additional tablet if my cravings are not managed with one tablet.
B. I need to rise slowly to a standing position while taking this medication.
C. I should not consume alcohol while taking this medication.
D. I should stop taking this medication if I notice adverse effects.
E. I will contact the health care provider if I experience dizziness or heart palpitations.

Correct Answer: B,C,E

Rationale: B: Rising slowly prevents orthostatic hypotension, a methadone side effect. C: Avoiding alcohol reduces CNS depression risk. E: Reporting dizziness or palpitations ensures timely management of adverse effects. A is incorrect as extra doses require provider approval, and D is incorrect as stopping abruptly can cause withdrawal.

The nurse is caring for an 82-year-old client in the emergency department.
Nurses' Notes
0930:
The client reports shortness of breath and left-sided chest pain for 2 days. The client fractured the right femoral neck a month ago after a fall and decided against operative management. Since then, the client has been wheelchair dependent and takes acetaminophen for fracture pain management. The client was placed on continuous cardiac monitoring.

History and physical
Body System
Neurological
The client is awake, alert, and oriented to person, place, time, and situation; the client appears anxious

Pulmonary
Vital signs are RR 22, SpOz 89% on room air; bilateral breath sounds are clear; pain increases with inhalation; the client reports shortness of breath for the past 2 days; the client smoked 1 pack of cigarettes per day for 10 years.

Cardiovascular
Vital signs are T 99.8 F (37.7 C), P 110, BP 110/60; S1 and S2 are present; there are no murmurs, redness and edema of the right lower extremity are noted; sinus tachycardia is seen on the monitor, chest pain is reported as 7 on a scale of 0-10

Musculoskeletal
The client has osteoporosis, is wheelchair dependent, and is unable to bear weight on the right leg

Diagnostic Results
CT pulmonary angiography
1030: Pulmonary embolism is confirmed

Lower extremity doppler ultrasound
1100: Deep venous thrombosis is noted in the right lower extremity.

Which of the following statements by the nurse indicate a correct understanding of heparin therapy? Select all that apply.

A. Clients who have had recent surgeries or have a history of hemorrhagic stroke should not receive heparin.
B. Heparin is administered via IV infusion pump.
C. Heparin requires two licensed health care personnel to verify the infusion rate.
D. Heparin should be discontinued if platelets decrease significantly.
E. I will collect a blood specimen for a complete blood count and coagulation panel before heparin is initiated.
F. The heparin dose is adjusted based on frequently checked PT/INR results.

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

Rationale: A: Correct, as recent surgery or hemorrhagic stroke are contraindications due to bleeding risk. B: Correct, as heparin is typically administered via IV infusion pump for precise dosing. C: Correct, as high-risk medications like heparin often require dual verification. D: Correct, as significant platelet decrease may indicate heparin-induced thrombocytopenia, requiring discontinuation. E: Correct, as baseline CBC and coagulation panels are needed before starting heparin. F: Incorrect, as heparin dosing is adjusted based on aPTT, not PT/INR, which is used for warfarin.

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.

Select findings that require immediate follow-up.

A. The client is alert and oriented to time, place, person, and situation.
B. The client reports sudden-onset right-sided facial drooping.
C. Bilateral pupils are equal, round, and reactive to light and accommodation
D. Vital signs: RR 16
E. The client has a history of hypertension
F. The client has diabetes mellitus
G. Right-sided lower extremity weakness is seen

Correct Answer: B, G

Rationale: Sudden-onset right-sided facial drooping (B) and lower extremity weakness (G) are signs of a possible stroke, requiring urgent evaluation. Being alert (A), normal pupils (C), and normal respiratory rate (D) are stable findings. Hypertension (E) and diabetes (F) are chronic and less urgent in this context.

The nurse is caring for a client at a women’s health clinic.
History & Physical
Labor and delivery unit
0800:
A 28-year-old nulliparous female comes to the clinic for confirmation of suspected pregnancy due to amenorrhea and a positive home pregnancy test. The client's current exercise regimen includes indoor cycling and outdoor running. The client reports nausea, vomiting, and breast tenderness. She has a 28-day menstrual cycle, and her last menstrual period was March 10- 17. The health care provider notes a bluish-purple vaginal mucosa and cervix during pelvic examination and confirms a 12-week intrauterine pregnancy by sonography. A fetal heart rate of 155/min is detected with handheld Doppler.

Progress Notes
Trending Maternal Weight
Prepregnancy
Height: 5 ft 5 in (165.1 cm)
Weight: 140 lb (63.5 kg)
BMI: 23.3 kg/m
12 weeks gestation
Weight: 150 lb (68 kg)
16 weeks gestation
Weight: 160 lb (72.6 kg)

Nurses’ notes
0800
Client comes to the clinic for a 20-week gestation prenatal visit. Client reports no bleeding or cramping. Vital signs and physical examination are normal. Current weight is 157 lb (71.2 kg). Client states that she is feeling well overall.

What client statement requires additional teaching reinforcement?

A. I added gymnastics into my exercise routine.
B. I eat carbohydrates that are high in fiber.
C. I eat salmon once per week.
D. I go to an indoor cycling class 3 times per week.

Correct Answer: A

Rationale: Gymnastics poses a risk of falls and injury during pregnancy, requiring reinforcement about safe exercises like walking or prenatal yoga.