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The nurse in an inpatient mental health unit is caring for a 43-year-old client.
History
Admission:
The client comes to the inpatient psychiatric facility for an evaluation. The client is having distressing nightmares, flashbacks, and feelings of being "on edge" since a severe motor vehicle collision 6 months ago that resulted in the death of the client's sibling. The client blames self for the sibling's death and verbalizes feelings of guilt. The client reports an inability to sleep well and being quick to anger, both of which led to job loss and the client seeking help. The client reports a loss of interest in previously enjoyed activities, such as working out and interacting with friends. The client has started smoking cigarettes daily since the collision and typically consumes ≥4 alcoholic beverages per day. Mental status examination reveals an irritable, guarded, and easily distracted mood. The client's appearance is well- kept, and grooming and hygiene are appropriate. The client’s speech is hyperverbal yet coherent, and thought process is organized. The client admits to feelings of hopelessness after the death of the sibling. The client reports occasionally seeing "shadows" but no visual hallucinations. The client has no homicidal ideations or history of violence toward others.
Vital signs: P 78, RR 17, BP 132/78.
The nurse suspects that the client is experiencing posttraumatic stress disorder. Which of the following symptoms are consistent with this condition? Select all that apply.
- A. Euphoric mood
- B. Flashbacks
- C. Hypervigilance
- D. Irritability
- E. Nightmares
- F. Self-blame
Correct Answer: B,C,D,E,F
Rationale: Posttraumatic stress disorder (PTSD) is characterized by symptoms such as flashbacks, hypervigilance, irritability, nightmares, and self-blame following a traumatic event. Euphoric mood is not associated with PTSD.
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The nurse is caring for a client on the medical-surgical unit.
History
Admission
0500: The client is admitted with an abscess and cellulitis of the right leg. The abscess is noted on the lateral aspect of the right calf, with redness, swelling, and warmth extending from the knee to the ankle. The abscess was incised in the emergency department, and a moderate amount of purulent, yellowish-green drainage was noted. The leg was wrapped with gauze, and the client received the first dose of IV antibiotics and opioids for pain control.
The client reports chronic lower back pain and gastrosophageal reflux disease, and he was admitted to the hospital once last year for gastrointestinal bleeding. He is currently prescribed daily pantoprazole but takes it only a few times a week.
Vital signs: T 100.9 F (38.3 C), P 82, RR 14, BP 130/80, SpO, 95% on room air
Progress Notes
Medical-Surgical Unit
2300:
The client reports nausea, headache, and insomnia. The client is trembling, diaphoretic, and restless.
The client states, "I would sleep better if those mice and cats would stop climbing up and down the walls."
The upper portion of the clients dressing is saturated with yellowish-green drainage. The peripheral V was removed by the client, and dried blood is noted at the IV site. The IV catheter is on the floor. The client yelled and pushed the nurse's hands away during inspection of the IV site.
Vital signs: T 99 F (37.2 C), P 102, RR 18, BP 170/96, SpO≥ 95% on room air
The nurse recognizes that the client is most at risk for ___ related to ___
- A. Seizures
- B. Septic shock
- C. Hypovolemic shock
- D. Cellulitis
- E. Substance withdrawal
- F. Gastrointestinal bleeding
Correct Answer: A,E
Rationale: Seizures are a significant risk in alcohol withdrawal syndrome, which is suggested by the client's symptoms of trembling, diaphoresis, restlessness, and hallucinations.
The nurse is caring for a client at a women’s health clinic.
History & Physical
Labor and delivery unit
0800:
A 28-year-old nulliparous female comes to the clinic for confirmation of suspected pregnancy due to amenorrhea and a positive home pregnancy test. The client's current exercise regimen includes indoor cycling and outdoor running. The client reports nausea, vomiting, and breast tenderness. She has a 28-day menstrual cycle, and her last menstrual period was March 10- 17. The health care provider notes a bluish-purple vaginal mucosa and cervix during pelvic examination and confirms a 12-week intrauterine pregnancy by sonography. A fetal heart rate of 155/min is detected with handheld Doppler.
For each client finding, click to specify if the finding is consistent with presumptive, probable, or positive signs of pregnancy. Note: Each row must have one response option selected
- A. Amenorrhea
- B. Chadwick sign
- C. Fetal heart rate
- D. Nausea/vomiting
- E. Breast tenderness
- F. Home pregnancy test
- G. Fetus visible on ultrasound
Correct Answer: A: Presumptive, B: Probable, C: Positive, D: Presumptive, E: Presumptive, F: Probable, G: Positive
Rationale: Presumptive signs are subjective and may have other causes (e.g., amenorrhea, nausea/vomiting, breast tenderness). Probable signs are objective but not definitive (e.g., Chadwick sign, positive home pregnancy test). Positive signs confirm pregnancy (e.g., fetal heart rate, fetus visible on ultrasound).
The nurse in the emergency department is caring for a 62-year-old client.
History and Physical
Neurological
The client is alert and oriented to time, place, person, and situation; the client reports sudden-onset right-sided facial drooping, speech is slurred; positive right-sided arm drift is seen
Eye, Ear, Nose, and Throat (EENT)
Bilateral pupils are equal, round, and reactive to light and accommodation
Pulmonary
Vital signs: RR 16, SpO, 95% on room air, lung sounds are clear bilaterally
Cardiovascular
Vital signs: T 99 F (37.2 C), P 86, BP 166/90; S1 and S2 are heard on auscultation; no murmurs are noted; the client has a history of hypertension
Musculoskeletal
Right-sided lower extremity weakness is seen
Endocrine
The client has diabetes mellitus
Psychosocial
The client reports drinking one glass of wine each evening with dinner, no tobacco use, and a history of major depression; the client takes sertraline.
Laboratory Results
During Admission
Blood Chemistry.
Glucose: 72 mg/dL (4.0 mmol/L)
Sodium: 133 mEq/L (133 mEq/L)
Chloride: 101 mEq/L (101 mmol/L)
Potassium: 3.7 mEq/L (3.7 mmol/L)
Laboratory Test and Reference Range
Blood Chemistry.
Glucose 74-106 mg/dL (4.1-5.9 mmol/L)
Sodium 136-145 mEq/L (136-145 mmol/L)
Chloride 98-106 mEq/L(98-106 mmol/L)
Potassium 3.5-5.0 mEq/L (3.5-5.0 mmol/L
Diagnostic Results
Admission
CT scan of the head without contrast
1830:
No areas of hemorrhage are noted
The client is diagnosed with ischemic stroke. For each potential intervention, click to specify if the intervention is indicated, not indicated for the care of the client.
- A. Obtain a 12-lead ECG
- B. Implement fall risk precautions
- C. Offer the client small sips of water
- D. Perform frequent neurologic assessments
- E. Ensure tissue plasminogen activator is available
- F. Apply sequential compression device to bilateral lower extremities
Correct Answer: A: Indicated, B: Indicated, C: Not Indicated, D: Indicated, E: Indicated, F: Indicated
Rationale: An ECG (A) monitors for cardiac causes of stroke. Fall precautions (B) address weakness-related risks. Frequent neurologic assessments (D) track stroke progression. tPA availability (E) is crucial for potential thrombolytic therapy. Sequential compression devices (F) prevent DVT in immobile patients. Oral intake (C) is contraindicated due to aspiration risk from dysphagia.
The nurse in the emergency department is caring for a 62-year-old client.
History and Physical
Neurological
The client is alert and oriented to time, place, person, and situation; the client reports sudden-onset right-sided facial drooping, speech is slurred; positive right-sided arm drift is seen
Eye, Ear, Nose, and Throat (EENT)
Bilateral pupils are equal, round, and reactive to light and accommodation
Pulmonary
Vital signs: RR 16, SpO, 95% on room air, lung sounds are clear bilaterally
Cardiovascular
Vital signs: T 99 F (37.2 C), P 86, BP 166/90; S1 and S2 are heard on auscultation; no murmurs are noted; the client has a history of hypertension
Musculoskeletal
Right-sided lower extremity weakness is seen
Endocrine
The client has diabetes mellitus
Psychosocial
The client reports drinking one glass of wine each evening with dinner, no tobacco use, and a history of major depression; the client takes sertraline.
Laboratory Results
During Admission
Blood Chemistry.
Glucose: 72 mg/dL (4.0 mmol/L)
Sodium: 133 mEq/L (133 mEq/L)
Chloride: 101 mEq/L (101 mmol/L)
Potassium: 3.7 mEq/L (3.7 mmol/L)
Laboratory Test and Reference Range
Blood Chemistry.
Glucose 74-106 mg/dL (4.1-5.9 mmol/L)
Sodium 136-145 mEq/L (136-145 mmol/L)
Chloride 98-106 mEq/L(98-106 mmol/L)
Potassium 3.5-5.0 mEq/L (3.5-5.0 mmol/L
Diagnostic Results
Admission
CT scan of the head without contrast
1830:
No areas of hemorrhage are noted
The nurse is assisting the registered nurse in planning care for a client prescribed tissue plasminogen activator (tPA) therapy. Which of the following actions are appropriate prior to administration? Select all that apply.
- A. Ask the client's caretaker about a history of recent surgery or trauma
- B. Maintain BP ≤ 185/110
- C. Plan to initiate subcutaneous heparin immediately after tPA infusion is complete
- D. Review the client's current home medication list
- E. Verify the exact time the stroke symptoms started
Correct Answer: A, B, D, E
Rationale: Recent surgery/trauma (A) is a contraindication for tPA. BP ≤ 185/110 (B) is required to reduce bleeding risk. Reviewing medications (D) identifies anticoagulants that contraindicate tPA. Verifying symptom onset time (E) ensures tPA is within the therapeutic window. Heparin post-tPA (C) increases bleeding risk and is not immediate.
The nurse in the emergency department is caring for a 62-year-old client.
Progress Notes
Emergency Department
0900: The client is brought to the emergency department by a family member after being found confused and lethargic. On arrival, the client is obtunded and does not respond to verbal stimuli.
Medical history includes major depressive disorder and chronic neck and back pain after a motor vehicle collision 2 years ago. The family member states that the client takes multiple medications but does not know which kind. The client was divorced a few months ago.
Physical examination shows 1-mm pupils, shallow breathing, and reduced bowel sounds. Fingerstick blood glucose is 78 mg/dL (4.3 mmol/L). ECG reveals normal sinus rhythm. Breath alcohol test is negative.
Vital signs: T 98.1 F (36.7 C), P 62, RR 8, BP 80/40, SpO, 94% on room air.
1800:
The client is awake, alert, and oriented to person, place, time, and situation. The client is experiencing severe withdrawal symptoms and is admitted for supervised detoxification.
Laboratory Results
Urine Drug Screen
On admission
Cocaine- Negative
Opioids- Positive
Amphetamines- Negative
Marijuana- Positive
Phencyclidine-Negative
Benzodiazepines- Negative
Barbiturates- Negative
Laboratory Test and Reference Range
Cocaine- Negative
Opioids- Negative
Amphetamines- Negative
Marijuana- Negative
Phencyclidine- Negative
Benzodiazepines- Negative
Barbiturates- Negative
The nurse is helping the client prepare for discharge after 3 days of inpatient detoxification. Which of the following actions should the nurse take? Select all that apply.
- A. Assist the client to identify maladaptive behaviors
- B. Encourage participation in an opioid recovery support group
- C. Ensure that the client and family members are trained in the use of naloxone
- D. Obtain referrals for rehabilitation programs
- E. Reinforce education regarding prescribed opioid agonist medications
Correct Answer: A,B,C,D,E
Rationale: All are appropriate: A: Identifying maladaptive behaviors supports recovery. B: Support groups aid long-term sobriety. C: Naloxone training prevents overdose deaths. D: Referrals ensure continued care. E: Education on medications (e.g., methadone) ensures adherence.