Nokea
The nurse is caring for a 21-year-old client.
Nurses' Notes History and Physical Vital Signs
Emergency Department
0800: The client comes to the emergency department due to fear of having a heart attack. The client reports, "I was taking the bus home from work when my chest started feeling really tight. I'm lucky my friend was there and able to help me get to the hospital. What if my friend is not there next time?" The client describes experiencing similar episodes recently at random places and times and worries about when or where the next attack will occur
The nurse recognizes that the client is at highest risk for developing Select..... evidenced by Select......
- A. Heart failure
- B. Agoraphobia
- C. Thyroid storm
- D. Fear of future attacks
- E. Chest pain & palpitations
- F. Recent weight loss & loss of appetite
Correct Answer: B,D
Rationale: Fear of future attacks indicates risk for agoraphobia due to avoidance behavior in panic disorder.
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The nurse is caring for a 55-year-old client in the clinic.
History and Physical
Body System
Findings: General - The client reports cramping pain in the left calf that has worsened over the past year. The pain is precipitated by walking and is partially relieved with rest. The client reports difficulty walking more than 3 blocks. Height: 72 in (182.9 cm), weight: 250 lb (113.4 kg), BMI: 33.9 kg/m?
Pulmonary- Vital signs are RR 16, SpO, 97% on room air. Client reports smoking 1 pack of cigarettes daily for the past 35 years. Breath sounds are mildly decreased throughout with mild prolonged expiration. Client has a history of chronic obstructive pulmonary disease.
Cardiovascular- Vital signs are T 98.8 F (37.1 C), P 82, BP 146/82. S1 and S2 heard on auscultation. The left lower extremity (LLE) is cooler to touch than the right and appears shiny with sparse hair. LLE pulses: femoral 2+, popliteal 1+, posterior tibia 1+, dorsalis pedis audible with Doppler. LLE capillary refill >3 sec. Client has a history of hypertension.
Gastrointestinal- Client is obese. No tenderness, guarding, masses, bruits, or hepatosplenomegaly.
Click to highlight below the findings that require immediate follow-up.
- A. General - The client reports cramping pain in the left calf that has worsened over the past year. The pain is precipitated by walking and is partially relieved with rest. The client reports difficulty walking more than 3 blocks. Height: 72 in (182.9 cm), weight: 250 lb (113.4 kg), BMI: 33.9 kg/m²
- B. Pulmonary - Vital signs are RR 16, SpO2 97% on room air. Client reports smoking 1 pack of cigarettes daily for the past 35 years. Breath sounds are mildly decreased
- C. Cardiovascular - Vital signs are T 98.8 F (37.1 C), P 82, BP 146/82. S1 and S2 heard on auscultation. The left lower extremity (LLE) is cooler to touch than the right and appears shiny with sparse hair. LLE pulses: femoral 2+, popliteal 1+, posterior tibia 1+, dorsalis pedis audible with Doppler. LLE capillary refill >3 sec. Client has a history of hypertension.
- D. Gastrointestinal - Client is obese. No tenderness, guarding, masses, bruits, or hepatosplenomegaly.
Correct Answer: A,C
Rationale: Calf pain with walking and poor peripheral pulses/cool skin suggest peripheral artery disease, requiring urgent vascular evaluation.
Nurses' Notes
Vital Signs
Emergency Department
0800:
A 43-year-old client comes to the emergency department due to lower
back pain and bilateral leg weakness. The client reports that the
weakness began 3 days ago in the feet and has gradually worsened.
The client sought treatment today after becoming "so weak that I fell
while walking" and noticing new hand weakness and difficulty
swallowing. Back pain radiates down both legs and is rated as 5 on a
scale of 0-10. The client recently recovered from an illness with flu-like
symptoms. The client reports a history of hypertension and takes no
medications. Assessment of the lower extremities reveals muscle
strength of 2/5 and decreased sensation to pinprick. Achilles tendon
and patellar reflexes are decreased.
1000:
The client reports difficulty raising the arms and inability to squeeze the
fingers. The client reports chest tightness and difficulty breathing.
For each intervention, click to specify if the intervention is appropriate or inappropriate for the care of the client.
- A. Ensure bedside suction is set up
- B. Place a bag valve mask at the bedside
- C. Ensure intubation equipment is available
- D. Reposition the client in the bed every 2 hours
- E. Place the client on continuous cardiac monitoring
- F. Apply a sequential compression device to the legs
- G. Mark the appropriate surgical site for a tracheotomy
Correct Answer: A,B,C,D,E,F
Rationale: Suction , bag valve mask , intubation equipment , repositioning , cardiac monitoring , and compression devices prepare for GBS complications. Tracheotomy marking is premature.
The nurse is caring for a 55-year-old client in the clinic.
History and Physical
Body System
Findings: General - The client reports cramping pain in the left calf that has worsened over the past year. The pain is precipitated by walking and is partially relieved with rest. The client reports difficulty walking more than 3 blocks. Height: 72 in (182.9 cm), weight: 250 lb (113.4 kg), BMI: 33.9 kg/m?
Pulmonary- Vital signs are RR 16, SpO, 97% on room air. Client reports smoking 1 pack of cigarettes daily for the past 35 years. Breath sounds are mildly decreased throughout with mild prolonged expiration. Client has a history of chronic obstructive pulmonary disease.
Cardiovascular- Vital signs are T 98.8 F (37.1 C), P 82, BP 146/82. S1 and S2 heard on auscultation. The left lower extremity (LLE) is cooler to touch than the right and appears shiny with sparse hair. LLE pulses: femoral 2+, popliteal 1+, posterior tibia 1+, dorsalis pedis audible with Doppler. LLE capillary refill >3 sec. Client has a history of hypertension.
Gastrointestinal- Client is obese. No tenderness, guarding, masses, bruits, or hepatosplenomegaly.
Which of the following statements should the nurse include in the teaching? Select all that apply.
- A. Elevate your legs several times during the day to relieve pain.'
- B. Incorporate more fruits and vegetables into your diet.'
- C. Inspect your feet daily for any wounds.'
- D. Use a heating blanket if your legs get cold.'
- E. Walk each day until you have leg pain, rest for 10 minutes, and then continue walking.'
Correct Answer: B,C,E
Rationale: Healthy diet , foot inspections , and supervised walking are appropriate. Elevation is for venous issues, and heating blankets risk burns in poor perfusion.
The newborn nurse is attending births in the labor and delivery unit.
Nurses' Notes
Labor and Delivery Unit
0000: A 39-year-old client, gravida 4 para 3, at 38 weeks gestation arrives at the labor and delivery unit reporting contractions every 2-3 min. During this pregnancy, the client was diagnosed with gestational diabetes mellitus and prescribed insulin, but she reports not taking the insulin. The client reports cigarette smoking (3-5 cigarettes/day) but denies alcohol or recreational drug use. The client received treatment for bacterial vaginosis during the second trimester. The client has gained 55 lb (25 kg) during the pregnancy. Group B Streptococcus result is negative.
Click to highlight below the 3 findings that should concern the nurse.
- A. The client was diagnosed with gestational diabetes mellitus and prescribed insulin, but she reports not taking the insulin.
- B. The client reports cigarette smoking (3-5 cigarettes/day) but denies alcohol or recreational drug use.
- C. The client received treatment for bacterial vaginosis during the second trimester.
- D. The client has gained 55 lb (25 kg) during the pregnancy. Group B Streptococcus result is negative.
Correct Answer: A,B,D
Rationale: Non-compliance with insulin , smoking , and excessive weight gain increase neonatal risks.
The nurse is caring for a 40-year-old client.
History Admission:
The client is brought to the psychiatric emergency department by ambulance after being observed walking in the street and shouting at vehicles. The client states that aliens are trying to attack him and that he is now on a mission to find and kill them. The clients mother says that last year he believed that he was being watched by an unidentified government agency and subsequently broke up with his girlfriend, quit his job, and disconnected his phone. The mother has noticed that he no longer seems to care about activities that used to interest him, and last month she discovered that he had moved into the family garden shed with his dog.
On examination, the client is malodorous and disheveled and laughs for no apparent reason. He appears anxious, avoids eye contact, and shows little emotion. His answers are very brief, and he asks if the interview is being secretly recorded. The client's speech is difficult to follow, and he repeatedly says in a monotone voice, "I said I'll find them." He later becomes angry and refuses to sit in a chair for the interview. I'll find them." He later becomes angry and refuses to sit in a chair for the interview.
For each finding, click to specify whether the finding indicates that the client's status has improved or not improved.
- A. Client is seen talking alone in the hallway
- B. Client is seen playing board games with peers
- C. Client asks the technician for hygiene supplies
- D. Client states, 'The voices are a part of my illness.'
- E. Client refuses to take medication from a new nurse
- F. Client is willing to eat food that is prepackaged only
Correct Answer: B,C,D
Rationale: Social interaction , hygiene requests , and insight into illness show improvement. Talking alone , medication refusal , and food paranoia indicate ongoing symptoms.