Nokea
Nurse Notes
0900
Pain assessment completed. The client's pain is 2/10. The client requests sleeping medication for the night. She states that she has horrible thoughts and memories about the house collapsing all the time and that it is keeping her from falling asleep. She states, "I used to be so happy before all of this happened. Now I can't seem to get out of this funk I am in." The client would also prefer to be in a quieter area of the unit as she is currently by the nurses' station and hears talking and alarms constantly.
1100
The nurse reviews the physician's orders for clonazepam and gives the medication as ordered.
1115
Start clonazepam 0.25 mg PO every 12 hours
What nursing interventions are appropriate for the client starting clonazepam? Select all that apply.
- A. Assist the client to the bathroom
- B. Assess mental status regularly
- C. Provide oral care at least twice a day
- D. Screen for orthostatic hypotension
- E. Monitor calcium levels
- F. Have an opioid agonist at the bedside
Correct Answer: B,C,D
Rationale: Assessing mental status, providing oral care, and screening for orthostatic hypotension are appropriate for clonazepam's CNS effects and side effects like dry mouth. Bathroom assistance, calcium monitoring, and opioid agonists are irrelevant.
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History and Physical
Nurse's Notes
Orders
The client is in the hospital after her house collapsed during a hurricane. She has been in the intensive care unit for 2 weeks and moved today to the surgical floor to continue monitoring her respiratory function and to complete intravenous antibiotic administration.
For each client statement, click to highlight the statement(s) below that require follow-up teaching by the nurse.
- A. This diagnosis means that I am crazy.'
- B. I can learn to manage my thoughts better through therapy.'
- C. I can use holistic approaches like meditation to help my symptoms.'
- D. Many people have the same response to a stressful situation as I am having right'
- E. I am at high risk for post-traumatic-stress disorder because I have acute stress disorder'
- F. I will probably need to be on medication for the rest of my life.'
Correct Answer: A,C,D,F
Rationale: Statements about being 'crazy,' typical stress responses, holistic approaches, and lifelong medication need clarification to address stigma, variability in trauma responses, and treatment plans.
The nurse is using the CAGE questionnaire as a screening tool for a client who is seeking help because his wife said he had a drinking problem. Which information should the nurse explore in-depth with the client based on this screening tool?
- A. Cancer screening results, anger, gastritis, daily alcohol intake.
- B. Consumption, liver enzyme, gastrointestinal complaints, and bleeding.
- C. Efforts to cut down, annoyance with questions, guilt, and drinking as an 'Eye-opener.'
- D. Minimizes drinking, frequently misses family events, guilt about drinking, and amount of daily intake.
Correct Answer: C
Rationale: The CAGE questionnaire assesses alcohol dependency through efforts to cut down, annoyance, guilt, and eye-opener drinking, which should be explored in-depth.
The nurse is admitting a male client who takes lithium carbonate twice a day. Which information should the nurse report to the healthcare provider immediately?
- A. Five-pound (2.3 kg) weight gain.
- B. Nausea and vomiting.
- C. Short-term memory loss.
- D. Depressed affect.
Correct Answer: B
Rationale: Nausea and vomiting may indicate lithium toxicity, requiring immediate reporting. Other symptoms are concerning but less urgent.
A client is admitted to the mental health unit and sits in the corner of the day room. When the nurse begins the admission assessment interview, the client is guarded, suspicious, and resists talking. Which action should the nurse implement?
- A. Postpone the client interview until the next day.
- B. Document the client's paranoid behavior.
- C. Attempt to ask the client simple questions.
- D. Ask another nurse to talk with the client.
Correct Answer: C
Rationale: Attempting to ask the client simple questions is a non-threatening approach that allows the nurse to start the assessment and establish rapport. Postponing delays care, documenting should follow engagement, and involving another nurse is a later option.
Laboratory Test
Result
Glucose
75 mg/dL (4.2 mmol/L)
Reference Range
74 to 106 mg/dim (4.1 to 5.9 mmol/L)
Click to highlight the assessment findings that require IMMEDIATE follow-up by the nurse. The client is a 68-year-old with a history of diabetes, hypertension (HTN), coronary artery disease (CAD), and recently diagnosed with end-stage renal disease (ERSD). She has been on hemodialysis three times a week for one month and presents to the emergency department (ED) with: Fatigue, Generalized weakness, Muscle cramps, Tingling sensation in her arms and legs, Lightheadedness. She also reports having missed her scheduled dialysis for the past 2 days, coupled with complaints of nausea, poor appetite, and an inability to attend the dialysis sessions.
- A. Muscle cramps
- B. Tingling sensation in her arms and legs
- C. Lightheadedness
- D. Fatigue
- E. Generalized weakness
Correct Answer: A,B,C
Rationale: Muscle cramps, tingling sensation, and lightheadedness are signs of electrolyte imbalance, likely due to missed dialysis, which can lead to serious complications like cardiac arrhythmias. The nurse should monitor vital signs, neurological status, and notify the physician.