Nokea
The nurse is caring for a 37-year-old client.
Admission Note
Antepartum Unit
1100:
The client, gravida 2 para 1 at 34 weeks gestation, is admitted to the hospital with right upper quadrant pain. The client
reports feeling extremely fatigued and nauseated and has vomited 3 times in the past 2 hours.
Physical examination shows right upper quadrant tenderness. Lower extremities have 2+ pitting edema; deep tendon
reflexes are 3+.
Laboratory Results
Laboratory Test and Reference Range, Admission
Hematology.
Platelets
150,000-400,000/mm3
(150-400 x 10°/L),
82,000/mm3
(82 x 10%/L)
Hemoglobin (pregnant)
>11 g/dL
(>110 g/L),
9.6 g/dL
(96 g/L)
Blood Chemistry.
Creatinine
Female: 0.5-1.1 mg/dL
(44.2-97.2 umol/L),
1.5 mg/dL
(114.4 umol/L)
Alanine aminotransferase
4-36 U/L
(0.07-0.60 ukat/L),
265 U/LI
(4.43 pkat/L)
Aspartate aminotransferase
0-35 U/LI
(0-0.58 ukat/L),
308 U/L
(5.14 ukat/L)
Lipase
0-160 U/L,
53 U/L
Amylase
30-220 U/L,
75 U/L
Urine Dipstick
Protein,
Increased
Vital Signs
1100
T,98.6 F (37 C)
P, 112
RR,20
BP,150/80
SpO2.98% on room air
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 the condition, and 2 parameters the nurse should monitor to measure the client's progress.
- A. Administer magnesium sulfate, Encourage small, frequent meals, Administer morphine, Prepare the client for birth, Administer a proton pump inhibitor
- B. Pancreatitis, HELLP syndrome, Hyperemesis gravidarum, Gastroesophageal reflux disease
- C. Lipase level, Urine ketones, Parameters to Monitor, Clotting factors, Postprandial pain , Deep tendon reflexes
Correct Answer:
Rationale: HELLP (Hemolysis, Elevated Liver enzymes, and Low Platelet count) syndrome is a life-threatening pregnancy-related disorder that typically
occurs >20 weeks gestation. Although HELLP syndrome is often considered a variant of preeclampsia, clients can develop this syndrome
without hypertension or proteinuria. Clinical manifestations may include elevated liver enzymes, right upper quadrant pain (due to swelling of
the liver), malaise, nausea, and decreased platelet count.
Appropriate interventions include:
• Preparing the client for birth, which is the only definitive treatment
• Assisting with the initiation of magnesium sulfate infusion for seizure prophylaxis
• Administering antihypertensive medications PRN to help prevent stroke
• Evaluating deep tendon reflexes frequently to monitor for hyperreflexia and clonus, which may indicate increased central nervous
system irritability and precede eclampsia; hyporeflexia may indicate magnesium toxicity.
• Monitoring clotting factors to evaluate bleeding risk and monitor for disseminated intravascular coagulation, a complication of HELLP
syndrome
You may also like to solve these questions
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 has reviewed the information from the Nurses' Notes. Complete the following sentence/sentences by choosing from the list/lists of options. After removing the blankets from the client's room, the nurse should ----------------and ----------
- A. Initiate 1-to-1 observation
- B. Request a prescription for alprazolam
- C. Lock the door to the client's room during the day
- D. Notify the health care provider
- E. Document the client's behavior
- F. Restrict the client to the unit unless accompanied by a family member
Correct Answer: D,A
Rationale: After removing the blankets from the client's room, the nurse should notify the health are provider and initiate 1-to-1observation.This client is at high risk for imminent suicide. The client has severe depression, suicidal ideation with a plan, and access to lethal means (eg, blankets that can be used for self-hanging). This client requires constant visual ontact (ie, 1-to-1observation) to ensure safety 24 hours a day. The nurse should also notify the health care provider to assess for underlying psychiatric disorders (eg, psychosis) that could contribute to the situation.
The nurse is caring for a 20-year-old female client.
Nurses' Notes
Urgent Care Clinic
0845: The parent brought the client to the clinic due to vomiting and weakness. The parent states that the client has experienced
sore throat and nasal congestion for the past week. The client has had 4 episodes of emesis during the past 24 hours and
diffuse, constant abdominal pain. The parent also reports that the client has had increased thirst and urine output over the
past 2 months.
The client's last menstrual period ended approximately 6 weeks ago with no abnormalities. Pregnancy status is unknown. The
client does not take any medications and does not use tobacco, alcohol, or recreational substances. Family history includes
hypertension and diabetes mellitus.
The client appears drowsy and is oriented to person and time only. The abdomen is soft without rigidity or rebound
tenderness, and bowel sounds are normal. No blood is present in emesis. Respirations are rapid and deep. Breath sounds
are clear.
Vital signs are T 98.8 F (37.1 C), P 128, RR 30, and BP 88/60 mm Hg.
Finger-stick blood glucose level is 600 mg/dL (33.3 mmol/L).
Laboratory Results
Laboratory Test and Reference Range, 0900
Glucose, serum (random)
≤200 mg/dL
(<11.1 mmol/L),
573 mg/dL
(31.8 mmol/L)
Potassium
3.5-5.0 mEq/L
(3.5-5.0 mmol/L),
5.7 mEq/L
(5.7 mmol/L)
The nurse reinforces teaching about managing diabetes mellitus during an acute illness. For each of the statements made by the client,click to specify whether the statement indicates correct understanding or incorrect understanding
- A. I should not take insulin if I cannot eat due to nausea.
- B. I should drink extra fluids to stay hydrated when I am experiencing an illness.
- C. I will check my blood glucose levels more frequently if I am experiencing an illness
- D. I need to check my urine for ketones if my blood glucose levels are persistently elevated
- E. I will reduce my carbohydrate intake if I experience high blood glucose levels during an
illness.
Correct Answer:
Rationale: When a client with diabetes mellitus experiences an infection or another illness, the release of stress hormones can cause increased insulin
resistance, which increases the blood glucose level and leads the body to break down fats for energy (ketosis). This can precipitate diabeti
ketoacidosis (DKA) as break down of fatty acids produces ketones. Interventions for managing diabetes mellitus and preventing DKA durin
an illness include:
• Increasing fluid intake to help clear ketones from the system and prevent dehydration during illness
• Checking blood glucose levels more frequently (eg, every 4 hr) to monitor for hyperglycemia
• Monitoring the urine for ketones if blood glucose levels are persistently elevated (>240 mg/dL [13.3 mmol/L]) for early detection of
impending DKA
• Consuming beverages that contain glucose and replacing electrolytes if nausea and vomiting are present
• Notifying the health care provider of persistently elevated blood glucose levels, ketones in the urine, high fever, nausea, vomiting, or
diarrhea
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.
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.
For each finding below, click to specify if the finding is consistent with the disease process of autism spectrum disorder, obsessive-compulsive disorder, or separation anxiety disorder. Each finding may support more than one disease process.
- A. Ritualized pattern of behavior
- B. Disinterest in social interaction
- C. Lack of spontaneous eye contact
- D. Restricted, fixated thoughts or interests
Correct Answer:
Rationale: Symptoms of autism spectrum disorder (ASD) range in severity from one individual to another. Clients often demonstrate a
ritualized pattern of behavior, resulting in distress and self-harm (eg, hitting the head) in response to changes in routine or
environment. Other manifestations include disinterest in social interaction, deficiency in verbal and nonverbal
communication (eg, lack of spontaneous eye contact or facial expressions), and restricted, fixated thoughts or interests
(eg, attached to unusual objects).
Obsessive-compulsive disorder (OCD) is characterized by obsessions (ie, restricted, fixated thoughts, impulses, or
images) and compulsions (ie, ritualistic, repetitive behaviors performed to reduce anxiety or prevent an adverse event).
These compulsions are time consuming and cause significant distress. In contrast to those with OCD, clients with ASD are not
bothered about their preoccupations or mannerisms and do not desire to change. Clients with OCD do not have issues with
social interaction or social-emotional reciprocity (eg, poor eye contact).
The nurse is performing a home health visit for an 84-year-old male.
History and Physical
Body System, Findings
General,
Client reports a 1-month-long history of fatigue and dyspnea that has worsened; he is unable to lie
flat and sleeps in a chair at night, medical history includes myocardial infarction, chronic heart
failure, chronic obstructive pulmonary disease, hypertension, and type 2 diabetes mellitus; client
was diagnosed with benign prostatic hyperplasia 8 months ago; client is adherent with prescribed
medications; client reports frequent consumption of donuts, hamburgers, steak, and fried chicken;
BMI is 34 kg/m?; client reports 6-Ib (2.7-kg) weight gain in 1 week
Neurological,
Alert and oriented to person, place, time, and situation
Pulmonary,
Vital signs: RR 24, SpOz 88% on room air; labored breathing, crackles in bilateral lung bases; client
expectorates frothy, pink-tinged sputum; client has a 40-year history of smoking 1 pack of cigarettes
per day
Cardiovascular,
Vital signs: T 98.8 F (37.1 C), P 98, BP 113/92; S1, S2, and S3 present; 3+ bilateral lower extremity
edema
Genitourinary, Concentrated yellow urine; client reports increased urinary hesitancy and urgency
Psychosocial,
Client reports being lonely and has depressed mental status
Complete the following sentence/sentences by choosing from the list/lists of options. The nurse should recognize that the client is most likely experiencing--------------as evidenced by------------------
- A. High BMI
- B. Obstructive sleep apnea
- C. A heart failure exacerbation
- D. A chronic obstructive pulmonary disease exacerbation
- E. Orthopnea
- F. History of smoking
Correct Answer: C,E
Rationale: The nurse should recognize that the client is most likely experiencing a heart failure (HF) exacerbation, as evidenced by
orthopnea. Orthopnea (ie, labored breathing in the supine position), decreased capillary oxygen saturation, extra heart tones
(eg, S3), bilateral lower extremity edema, >5 lb [2.3 kg] weight gain in 1 week, and adventitious lung sounds (eg, crackles)
indicate fluid overload