The nurse recognizes the client has most likely developed .....

The nurse is caring for a 75-year-old female client. Nurses' Notes Laboratory Results Diagnostic Results Emergency Department
The client is transferred to the emergency department from a skilled nursing facility for a 3-day history of left lower quadrant abdominal pain rated 8 on a scale of 0-10, loss of appetite, and nausea. Although the client has a history of chronic constipation, she has had 2 or 3 loose stools daily for 1 week. The client reports tenderness on deep palpation of the left lower quadrant. There is an area of blanchable redness on the coccyx. The stool is positive for occult blood.
The client has residual left-sided weakness from an ischemic stroke 2 years ago and ambulates with a walker. The client reports falling several times in the past 6 months; the last fall was 3 weeks ago No ecchymosis or injuries are noted. The client had a hysterectomy and salpingo-oophorectomy for uterine fibroids 20 years ago. Vital signs are T 100 F (37.8 C), P 98, RR 17, BP 126/68, and SpOz 97% on room air.
Medical-Surgical Unit: 4 Days Later
The client continues to experience left lower quadrant pain, decreased appetite, and nausea. Today, she developed chills. Stool frequency has not increased. Severe tenderness is noted in the left lower quadrant, and a mass is palpable. Vital signs are T 101.3 F (38.5 C), P 112, RR 17, BP 110/80, SpO, 97% on room air.

The nurse recognizes the client has most likely developed .........anticipate assisting with.........

A. An abscess
B. Colon cancer
C. Clostridiodes difficile infection
D. Collecting a stool culture
E. Preparing the client for a colostomy
F. Obtaining a repeat CT scan of the abdomen

Correct Answer: A,F

Rationale: A palpable mass and fever suggest an abscess , requiring a CT scan for confirmation.

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.

Which of the following statements by the nurse are appropriate to include in the teaching? Select all that apply

A. Avoid driving after taking alprazolam.'
B. Contact your health care provider immediately if you experience suicidal thoughts.'
C. Do not abruptly stop taking alprazolam because you may experience withdrawal symptoms.'
D. Limit alcoholic beverages to no more than one drink a day while taking alprazolam.'
E. Take sertraline at the onset of a panic attack.'

Correct Answer: A,B,C

Rationale: Alprazolam requires avoiding driving , monitoring for suicidal thoughts , and gradual tapering . Alcohol limits are stricter, and sertraline is not for acute attacks.

The nurse is caring for a 43-year-old client.
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

Which finding is the most concerning to the nurse at this time?

A. Bilateral leg weakness
B. Difficulty swallowing
C. Elevated blood pressure
D. Radiating lower back pain

Correct Answer: B

Rationale: Difficulty swallowing indicates bulbar involvement in Guillain-BarrÃ© syndrome, risking aspiration and requiring urgent intervention.

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 client is most likely experiencing ....... and is at risk for.......

A. Osteomyelitis
B. Rhabdomyolysis
C. Sickle acute cell pain episode
D. Sepsis
E. Ischemic organ damage
F. Compartment syndrome

Correct Answer: C,E

Rationale: Severe pain and tachycardia suggest a sickle cell pain episode , with risk for ischemic organ damage due to vaso-occlusion.

The nurse is caring for a 12-year-old client.
History and Physical Vital Signs Body System Findings
General- The client has a 2-day history of decreased appetite, nausea, fatigue, and headaches, the client had a "sore throat" 2 weeks ago that resolved without treatment; BMl is in the 65th percentile
Eye, Ears, Nose, and Throat (EENT)- Periorbital edema; no changes in vision
Pulmonary- Lung sounds clear bilaterally; no increased work of breathing; no cough Cardiovascular- S1 and S2 heard on auscultation; no murmur auscultated; 3+ bilateral lower extremity edema is noted
Gastrointestinal- Bowel sounds present, no masses or tenderness felt Musculoskeletal No joint pain or swelling
Genitourinary- Decreased urination; dark, cola-colored urine

Which condition does the nurse suspect?

A. Acute postinfectious glomerulonephritis
B. Hemolytic uremic syndrome
C. Rhabdomyolysis
D. Urinary tract infection

Correct Answer: A

Rationale: Cola-colored urine, edema, and recent infection point to acute postinfectious glomerulonephritis.