The nurse recognizes that the client is most likely experien...

The nurse is caring for a 23-year-old client. Nurses' Notes Vital Signs Medication Administration Record
Inpatient Unit Admission:
The client was found alone in a public park shouting at people who were not present. The client told the staff, "There's nothing wrong with me. It's just the effects of the microchip that was implanted in my head." The client is not oriented to place or time. Day 7: The client has developed confusion, fever, and diaphoresis. Speech is slurred Muscular rigidity is observed in all extremities. Deep tendon reflexes are 2+; no clonus is noted

The nurse recognizes that the client is most likely experiencing which is a complication of

A. Diabetes insipidus
B. Serotonin syndrome
C. Neuroleptic malignant syndrome
D. Lithium
E. Fluoxetine
F. Olanzapine

Correct Answer: C,F

Rationale: Neuroleptic malignant syndrome is a complication of antipsychotics like olanzapine , presenting with fever, rigidity, and confusion.

The nurse is caring for a 16-year-old client.
History and Physical Laboratory Results
Body System- Findings
General- The client comes to the emergency department with pain in the upper back, both knees, and the lower legs that is rated as 9 on a scale of 0-10; medical history includes sickle cell disease; the client reports attending an outdoor sports camp for the past 4 days; the client appears restless with frequent position changes and facial grimacing
Neurological- The client is alert and oriented to person, place, and time
Pulmonary- Vital signs: RR 24, SpOz 95% on room air, breath sounds are clear bilaterally Cardiovascular- Vital signs: T 98.4 F (36.9 C), P 120, BP 130/78; S1 and S2 are auscultated with no murmurs, continuous cardiac monitor shows sinus tachycardia
Gastrointestinal- The abdomen is soft and nontender with normal bowel sounds; the client vomited 30 mL of clear liquid
Musculoskeletal- The client has multiple, tender, bony points
Genitourinary- The client voided 50 mL of clear, amber-colored urine

The nurse should notify the health care provider about which client data?

A. Miosis of bilateral pupils
B. Most recent reticulocyte count
C. No bowel movement in 2 days
D. Pain rated as 2 on a scale of 0-10

Correct Answer: A

Rationale: Miosis suggests opioid overdose, requiring immediate provider notification.

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/mÂ²
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.

The nurse is caring for an infant in the clinic.
Nurses' Notes Clinic Visit: Age 4 Months
0800: The infant is playing with the hands and feet and making cooing sounds. The infant smiles and laughs appropriately when the caregiver provides a toy. No evidence of Moro, tonic, or rooting reflexes noted. The infant has weak muscle tone in the neck and does not hold the head up independently.
Clinic Visit: Age 6 Months
0930: The infant does not have head control. The caregiver reports that the infant babbles but does not use words or call the parent by any name. The infant does not point at desired objects. The caregiver also reports that the infant has begun to act afraid of unfamiliar people

The nurse recognizes that the 6-month-old infant who ........ should be evaluated for........

A. Does not use words
B. Lacks control of the head
C. Does not point at desired objects
D. Cerebral palsy
E. Hearing Impairment
F. Autism spectrum disorder

Correct Answer: B,D

Rationale: Lack of head control at 6 months is concerning for cerebral palsy , as it indicates delayed motor development.

The nurse is assisting the registered nurse with caring for a client who is at 36 weeks gestation. History and Physical Vital Signs
General - Client is gravida 2 para 1 at 36 weeks gestation; reports a throbbing headache rated as / on a scale of 0-10, blurred vision, and epigastric pain; client states that she took 1000 mg of acetaminophen 2 hours ago with no relief, medical history includes seasonal allergies and exercise-induced asthma
Neurological -Patellar deep tendon reflexes 2+ bilaterally, clonus absent
Cardiovascular -Heart tones normal; facial edema noted; +2 pitting edema in bilateral upper extremities; +3 pitting edema in bilateral lower extremities
Gastrointestinal -Client reports fetal movement, no contractions noted; soft uterine resting tone on palpation
Genitourinary -Cervical examination: 1 cm dilated, 0% effaced, -3 fetal station, cephalic fetal presentation, amniotic membranes intact; cesarean birth 5 years ago at 40 weeks gestation for breech fetal presentation, resulting in delivery of healthy newborn

For each potential intervention, click to specify if the Intervention is indicated or not indicated for the care of the client.

A. Initiate seizure precautions
B. Encourage frequent ambulation
C. Start a magnesium sulfate infusion
D. Prepare to administer antihypertensives

Correct Answer: A,C,D

Rationale: Seizure precautions , magnesium sulfate , and antihypertensives are indicated for preeclampsia with severe features. Ambulation is not prioritized due to risk of falls.

The nurse is caring for a 6-year-old client accompanied by the parents.
History and Physical
Body System
Findings
General
Client is brought to the emergency department due to
shortness of breath; medical history includes cystic fibrosis
and many previous hospital admissions for pneumonia; in the
3rd percentile for height and weight
Neurological
Alert and oriented to person, place, and time; no neurologic
deficits
Pulmonary
Vital signs: RR 30, SpO, 87% on room air; moderate
subcostal retractions; bilateral wheezing and coarse crackles
throughout lung fields with fine inspiratory crackles at left lung
base; paroxysmal coughing that produces thick, yellow,
blood-tinged sputum; parents report that the client has begun
to become "winded" after showering and other activities Cardiovascular
Vital signs: T 101.7 F (38.7 C), P 130, BP 94/58; skin warm
and dry; peripheral pulses palpable 2+; capillary refill 3
econds; mild finger clubbing noted
Gastrointestinal
Abdomen soft with normoactive bowel sounds; parent states,
"Swallowing the enzyme capsules is very difficult for my child,
and I have noticed an increase in greasy, bulky stools"

Which of the following parent statements indicate a correct understanding? Select all that apply.

A. A low-fat diet will help normalize my child's stool.'
B. I will encourage my child to get regular exercise.'
C. I will make sure that my child receives the flu vaccine each year.'
D. My child should perform daily breathing exercises, even if there are no symptoms.'
E. My child will require lifelong vitamin supplementation.'
F. The pancre-lipase capsules can be opened and sprinkled on food.'

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

Rationale: Exercise , flu vaccine , daily breathing exercises , vitamin supplementation , and sprinkling pancre-lipase are correct. A low-fat diet is incorrect; a high-calorie, high-fat diet is needed for cystic fibrosis.