Nokea
Nurses' Notes
Clinic Visit
0915:
The client reports substernal chest discomfort and intermittent palpitations that began this morning. Medical
history includes coronary artery disease and stable angina. Daily medications include aspirin, metoprolol,
atorvastatin, and lisinopril. The client has been traveling for the past week and ran out of one of the
medications.
Vital Signs 0915
T
98.2 F (36.8 C)
P
116
RR
16
BP
138/89
SpOz
98% on room air
The nurse is caring for a 65-year-old client in the clinic. Complete the following sentence by choosing from the list of options.The nurse suspects that the clients condition is most likely related to the abrupt discontinuation of-----------------
- A. Lisinopril
- B. Metoprolol
- C. Atorvastatin
Correct Answer: B
Rationale: Beta-adrenergic antagonists, also known as beta blockers (eg, metoprolol, atenolol), are commonly used to treat
hypertension, heart failure, and anxiety. Beta blockers reduce cardiac workload by inhibiting the action of catecholamines (eg,
epinephrine, norepinephrine) on beta-adrenergic receptors in the heart. This slows electrical conduction through the heart,
which decreases heart rate and blood pressure.
Abrupt discontinuation of beta blockers can result in rebound hypertension, angina, palpitations, myocardial infarction,
arrhythmias (eg, tachycardia, ventricular tachycardia), or sudden death. These discontinuation-associated risks are caused
by increased beta-adrenergic receptor sensitivity to circulating catecholamines, resulting in an increased sympathetic
response. Withdrawal symptoms should resolve after resumption of the medication.
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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.
Select below the 6 findings that require follow-up.
- A. enuresis at night
- B. recently relocated to a new home and school
- C. fatigue, irritability, and multiple
behavioral outbursts - D. frequently reports feeling
thirsty - E. weight in the 20th percentile
- F. Dry mucous membranes
- G. frequently requests to use
the bathroom while at school
Correct Answer: A,C,D,E,F,G
Rationale: The nurse should follow up on the following findings:
irritability may manifest as behavioral outbursts.
• Frequent urination and nocturnal enuresis: Frequent urination and involuntary voiding in a child who was previously
toilet trained for at least 6 months indicate excessive urination (ie, polyuria), which is a characteristic finding of multiple
medical conditions (eg, diabetes mellitus [DM], diabetes insipidus).
• Increased thirst and dry mucous membranes: Increased thirst (ie, polydipsia) and dry mucous membranes are signs
of dehydration. Dehydration in the presence of polyuria and weight loss is concerning for DM.
• Weight loss: Weight loss is a common finding in clients with DM because the body is unable to use glucose and instead
breaks down protein and fat stores for energy.
• Fatigue, irritability, and multiple behavioral outbursts: Fatigue and irritability in a client with polydipsia and polyuria
may indicate an energy deficit from altered glucose metabolism related to DM. In a 6-year-old client, fatigue and
The nurse is caring for a 64-year-old client.
History and Physical
Body System, Findings
General ,
The client reports a 24-hour history of blurred vision and redness in the left eye with a left-sided headache.
This evening, the client developed acute, severe pain in the left eye accompanied by occasional nausea and
vomiting. The client reports no use of systemic or topical eye medications. Medical history includes
osteoarthritis and hypercholesterolemia.
Eye, Ear, Nose, and Throat (EENT),
The client wears eyeglasses to correct farsighted vision. Right eye: pupil 2 mm and reactive to light,
conjunctiva clear. Left eye: pupil 4 mm and nonreactive to light with red conjunctiva. Bilateral lens opacity is noted.
Pulmonary,
Vital signs are RR 20 and SpO, 96% on room air. The lungs are clear to auscultation bilaterally.
Cardiovascular,
Vital signs are T 99 F (37.2 C), P 88, and BP 140/82.
Psychosocial,
The client reports a great deal of emotional stress following the recent death of the client's spouse that is accompanied by lack of sleep, poor appetite, and a 7.9-lb (3.6-kg) weight loss within the past month. The client takes diphenhydramine for sleep.
The nurse reinforces discharge teaching to the client after laser peripheral iridotomy. Which of the following client statements indicate an understanding of the teaching? Select all that apply.
- A. Gently pulling down my lower eyelid creates a pocket where I should administer the drops.
- B. I will apply pressure over the inner corner of my eye after administering each medication
- C. I will stop taking diphenhydramine because it can cause a glaucoma attack.
- D. I will wait 5 minutes between administering each eye drop medication.
- E. Touching my eye with the medication applicator may cause an infection.
Correct Answer: A,B,C,D,E
Rationale: Laser peripheral iridotomy is a surgical intervention for acute angle-closure glaucoma (ACG) that involves creating a small hole in the iris to
prevent the drainage pathway from closing and improve movement of aqueous humor into regular outflow channels. Ophthalmic alpha-
adrenergic agonists (eg, apraclonidine, brimonidine) are administered postoperatively to reduce aqueous humor production and prevent an
elevation in intraocular pressure.
Important considerations for the administration of ophthalmic drops include:
• Pulling the lower eyelid down by gently pressing on the lower orbital bone to expose the conjunctival sac (Option 1)
• Applying pressure over the inner corner of the eye (eg, lacrimal duct) after each medication to avoid systemic absorption (Option 2)
• Waiting at least 5 minutes before instilling a different medication into the same eye to allow absorption of the first medication and to
avoid overflow with multiple drops (Option 4)
• Holding the dropper ½*% in (1-2 cm) above the conjunctival sac to prevent contamination of the dropper and infection of the eye
(Option 5)
Clients should also be instructed to consult with their health care provider before taking over-the-counter medications (eg, decongestants,
anticholinergics, antihistamines) because a subsequent episode of acute ACG may be triggered by certain medications (Option 3).
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 implemented the prescribed therapies and is now assisting the client to fill out the lunch menu. Which meal choice is best for this client?
- A. Black beans and rice, sliced tomatoes, and a banana
- B. Grilled chicken sandwich, corn on the cob, and applesauce
- C. Hamburger patty on a whole wheat bun with avocado
- D. Salmon, green peas, baked potato, and strawberries
Correct Answer: B
Rationale: This client is experiencing hyperkalemia and should reduce dietary intake of potassium. The preferred meal choice for this client would
include lean meat, such as chicken, that is grilled rather than cooked in oil, and side dishes consisting of fruits and vegetables low in
potassium, such as corn and applesauce (Option 2).
(Options 1, 3, and 4) Beans (a legume), salmon, tomatoes, bananas, potatoes, strawberries, whole wheat products, and avocados are all
high-potassium foods that the client should avoid at this time. Clients with cardiovascular disease should not consume red meat (eg,
hamburger patty) except in limited quantity because it is high in saturated fat.
The nurse is caring for a 24-year-old client.
Nurses' Notes
Emergency Department
1300:
The client is brought to the emergency department after a motor vehicle collision in which the driver's side airbag deployed.
The client was driving the vehicle and was not restrained by a seat belt. The client reports shortness of breath and chest
pain on inspiration and expiration.
History and Physical
Body System ,Findings
Neurological,
Awake, alert, and oriented to person; pupils equal, round, and reactive to light and accommodation; client is
agitated and moves all extremities spontaneously but does not follow commands
Integumentary, Superficial lacerations to the face; diffuse bruising noted on upper extremities and chest wall
Pulmonary,
Vital signs: RR 30, SpOz 92% via nonrebreather mask; unilateral chest wall expansion observed on inspiration;
left-sided tracheal deviation noted; breath sounds diminished throughout the right lung field
Cardiovascular,
Vital signs: P 104, BP 90/58; S1 and S2 heard on auscultation; all pulses palpable; no extremity peripheral edema
noted
Psychosocial ,Alcohol odor noted on the client's breath
Select 5 findings that require immediate follow-up.
- A. SpO, 92% via nonrebreather mask
- B. unilateral chest wall expansion observed on
inspiration - C. left-sided tracheal deviation noted;
- D. breath sounds diminished throughout the right lung
field - E. Superficial lacerations to the face
- F. BP 90/58; S1 and S2 heard on auscultation; all pulses palpabl
Correct Answer: A,B,C,D,F
Rationale: The nurse should immediately follow up on the following findings:
• Hypoxemia (eg, SpO, 92% on 100% oxygen [nonrebreather mask]) indicates an abnormality with ventilation and/or perfusion.
• Unilateral chest wall expansion on inspiration indicates one side of the lung is not inflating. This is usually due to lung collapse,
which could be due to an internal airway dysfunction (eg, mucous plug blocking air entry) or external compression (eg, pneumothorax).
• Tracheal deviation (ie, displacement of the trachea to one side) occurs when pressure from one side of the chest is higher than the
other, pushing the mediastinal structures to the side with less pressure. This is usually due to a large hemothorax or pneumothorax.
• Diminished breath sounds indicate the lung is not adequately expanding (eg, atelectasis, pneumothorax).
• Hypotension (eg, BP 90/58 mm Hg) occurs from several mechanisms, including compression of the heart (eg, cardiac tamponade)
and/or great vessels (eg, tension pneumothorax), inadequate ventricular filling between heartbeats (eg, supraventricular tachycardia),
volume depletion, and other conditions
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 potential intervention, click to specify if the intervention is expected or not expected for the care of the client.
- A. Daily weights
- B. IV furosemide
- C. Fluid restriction
- D. Supplemental oxygen
- E. Antihypertensive medications
- F. Nebulized albuterol breathing treatments
Correct Answer:
Rationale: Expected interventions for acute decompensated heart failure (HF) focus on reducing cardiac workload and improving
oxygenation. These include:
• Daily weights should be performed to monitor fluid volume status and guide treatment. Ideally, daily weights should be
performed at the same time of day, on the same scale, and with the client wearing the same amount of clothing.
• Diuretics (eg, furosemide) prevent reabsorption of sodium and chloride in the kidneys, which increases fluid excretion in
urine and decreases preload. Diuretics provide symptomatic relief by reducing pulmonary congestion and peripheral
edema. These are the cornerstone of therapy and often a priority after oxygen therapy.
• Fluid restriction is indicated to decrease circulating fluid volume and prevent excess strain on the heart.
• Supplemental oxygen should be administered to improve oxygen delivery in clients with HF due to impaired gas
exchange from pulmonary edema.
• Antihypertensive medications reduce cardiac workload and improve contractility by lowering blood pressure (ie,
afterload).
Nebulized albuterol is a bronchodilator administered to improve oxygenation in clients with reactive airway disease (eg.
asthma, chronic obstructive pulmonary disease). Bronchodilators will not improve oxygenation in clients with pulmonary
edema and are not expected for treatment of HF.