Nokea
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"
The nurse should prioritize interventions for Select...
- A. Malabsorption of nutrients
- B. Alterations in blood glucose
- C. Decreased gastrointestinal motility
- D. Impaired clearance of airway secretions
Correct Answer: D
Rationale: Impaired airway clearance is a priority in cystic fibrosis exacerbations due to thick mucus causing respiratory distress and infection risk.
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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.
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.
Select to highlight below the 4 findings that require immediate follow up.
- A. The client is brought to the psychiatric emergency department by ambulance after being observed walking in the street and shouting at vehicles.
- B. The client states that aliens are trying to attack him and that he is now on a mission to find and kill them.
- C. The client's 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.
- D. 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.
Correct Answer: A,B,C,D
Rationale: Dangerous behavior , delusions with violent intent , paranoid history , and social withdrawal indicate acute psychosis requiring urgent intervention.
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 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
For each finding below, click to specify if the finding is consistent with the disease process of pneumonia or pulmonary embolism.
- A. Dyspnea
- B. Confusion
- C. High fever
- D. Recent surgery
- E. Smoking history
- F. Purulent sputum
Correct Answer: A,B,C,D,E
Rationale: Dyspnea , confusion , and smoking occur in both. Fever and sputum are specific to pneumonia, surgery to embolism.
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 intervention, click to specify if the intervention is appropriate or not appropriate for the care of the client.
- A. Allow the client to listen to music
- B. Use gentle touch to calm the client
- C. Open medication packages in front of the client
- D. Tell the client that you do not believe that the voices are real
- E. Ask the client if he is hearing voices instructing him to self-harm
Correct Answer: A,C,E
Rationale: Music , transparent medication administration , and assessing self-harm risk are appropriate. Touch may escalate agitation, and denying voices dismisses the client’s reality.