The nurse should notify the health care provider about which...

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 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

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 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.

Which complication of schizophrenia should the nurse be most concerned about?

A. Anxiety
B. Insufficient nutritional intake
C. Self-harm
D. Substance use disorder

Correct Answer: C

Rationale: Self-harm is the most urgent complication due to potential for immediate danger.

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. 1400: The newborn is delivered via forceps-assisted vaginal birth at
1400. The newborn was immediately placed in skin-to-skin contact with the mother, dried, and stimulated. Apgar scores are 7 at 1 minute and 9 at 5 minutes
1405: Newborn vital signs are T 97.3 F (36.3 C), P 156, and RR 52.
1415: Newborn weight is obtained. The newborn is 9 lb 15 oz (4500 g). The maternal client is assisted to latch the newborn onto the breast.
1430: Slight bruising to the scalp is noted where forceps were applied. Newborn vital signs are T 97.2 F (36.2 C), P 160, RR 55, and SpO 95% on room air.

For each nursing action, click to specify if the action is indicated or not indicated for the care of the newborn during a heel stick.

A. Warm the heel prior to initiating the procedure
B. Collect the first drop of blood for blood glucose testing
C. Draw blood by pricking the skin with a small-gauge needle
D. Obtain the blood specimen from the lateral aspect of the heel
E. Clean the heel with an alcohol pad prior to obtaining the blood specimen

Correct Answer: A,C,D,E

Rationale: Warming the heel , using a needle , lateral heel site , and cleaning are standard. The first drop is discarded to avoid contamination.

The nurse is caring for a 68-year-old client who is brought to the emergency department due to confusion.
History and Physical Body System Findings
General- Client's adult child reports the confusion started this morning, following 3 days of fever and productive cough; medical history includes small bowel resection 10 days ago, chronic heart failure, and coronary artery disease
Neurological- Client is drowsy and oriented to person only, but intermittently agitated Integumentary- Small abdominal surgical incision is present over lower left quadrant, edges are well approximated, and no redness or drainage is noted
Pulmonary- Vital signs are RR 24 and SpO 90% on room air; labored breathing is observed, and crackles and diminished breath sounds are auscultated over right lower chest; client is expectorating yellow sputum; history includes smoking a pack of cigarettes daily for the past 40 years
Cardiovascular- Vital signs are T 102.9 F (39.4 C), P 110, and BP 110/70; S1 and S2 are heard on auscultation; bilateral lower extremity edema is 1+; ECG shows sinus tachycardia
Gastrointestinal- Normoactive bowel sounds are auscultated; client's last bowel movement was 1 day ago
Genitourinary- Client voided concentrated yellow urine

The nurse is monitoring the client after insertion of a chest tube that is connected to a water seal chamber device. Which of the following observations are anticipated? Select all that apply

A. Chest tube collection container positioned above the chest tube insertion site.
B. Dependent loop in the drainage tube from the insertion site
C. Intermittent bubbling in the water seal chamber
D. Sterile gauze dressing taped on three sides
E. Tidaling in water seal chamber with inspiration and expiration

Correct Answer: C,E

Rationale: Bubbling and tidaling indicate a functioning chest tube system.

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.