Nokea
History and Physical
Nurses' Notes
Flow Sheet
Laboratory Results
The nurse is caring for a client who was admitted to the hospital with reports of shortness of breath, fever, fatigue, and oral thrush three days ago. The health care provider reviews the laboratory and diagnostic tests with the client and informs of the diagnosis of Pneumocystis pneumonia. The client reports that they recently tested HIV positive. The nurse reviews the client's medical record.
HIV diagnosed 4 months ago with no medications prescribed.
Note added to H&P reporting client wishes to be confidential since family and friends are unaware of the HIV diagnosis.
What order(s) should the nurse anticipate being prescribed after an update is reported to the healthcare providers? Select all that apply.
- A. Increase IV fluids to 150 mL/hr
- B. Monitor for adverse reaction to antibiotics
- C. Repeat CD4+ T-cell count STAT
- D. Initiate airborne isolation
- E. Administer antiemetic
Correct Answer: A,B,E
Rationale: Increasing IV fluids, monitoring for antibiotic reactions, and administering an antiemetic address the client's fever, potential infection, and nausea associated with Pneumocystis pneumonia.
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A client who has small cell carcinoma of the lung is admitted with symptoms of syndrome of inappropriate antidiuretic hormone (SIADH). As the client's serum sodium level increases from 120 mEq/L to 125 mEq/L, which intervention should the nurse implement?
- A. Assess for increasing fluid volume overload.
- B. Withhold next scheduled dose of treatment.
- C. Increase neurologic checks to every 2 hours.
- D. Maintain the prescribed fluid restriction.
Correct Answer: D
Rationale: Maintaining the prescribed fluid restriction is essential to prevent further dilutional hyponatremia and to help normalize the serum sodium level gradually.
The nurse is caring for a client in the post anesthesia care unit (PACU) who underwent a thoracotomy two hours ago. The nurse observes vital signs of a heart rate of 140 beats/minute, a respiratory rate of 26 breaths/minute, and a blood pressure of 140/90 mm Hg. Which intervention is most important for the nurse to implement?
- A. Administer IV fluid bolus as prescribed by the healthcare provider.
- B. Medicate for pain and monitor vital signs according to protocol.
- C. Encourage the client to splint the incision with a pillow to cough and deep breathe.
- D. Apply oxygen at 10 L/minute via non-rebreather mask and monitor pulse oximeter.
Correct Answer: B
Rationale: Medicating for pain and monitoring vital signs is the most important intervention, as the elevated vital signs are likely due to inadequate pain control following a thoracotomy, which can lead to increased sympathetic activity.
The nurse is providing teaching to a client about self-management of type 2 diabetes mellitus. Which information provided by the client indicates understanding?
- A. Using salt, herbs, and spices will improve the flavor of foods.
- B. Restrict alcoholic beverages to no more than 1-2 per week.
- C. Eat a protein snack 30 minutes before any exercise workout.
- D. Get an influenza vaccine every year as soon as available.
Correct Answer: D
Rationale: Getting an influenza vaccine every year is a crucial aspect of diabetes self-management, as people with diabetes are at increased risk of complications from influenza.
Initial Assessment
Orders
A 34-year-old male client presents to the emergency department (ED) for an acute asthma attack which began after jogging through a local park. The client is able to answer questions, pausing every few words to catch his breath. The client reports using a rescue Inhaler three times, but he just couldn't catch his breath. The client reports that symptoms seem worse when outdoors and when exercising and that episodes like this make him extremely nervous. The client reports that it has been a couple of months since he had an asthma attack, and he came to the ED today because he noticed that his inhaler was expired and was worried the medication was not working.
The nurse has identified the priority problem for the client and now must determine proper care interventions. Based on the client history and the assessment data, what action(s) should the nurse anticipate? Select all that apply.
- A. Provide client teaching
- B. Apply oxygen via nasal cannula.
- C. Ask the client for a list of current medications.
- D. Place the client in Trendelenburg position.
- E. Notify the healthcare provider of the client's need for intubation.
- F. Administer medications as ordered.
Correct Answer: A,B,C,F
Rationale: Client education, oxygen therapy, obtaining medication history, and administering ordered medications address the client's asthma exacerbation and promote effective management.
History and Physical Nurses' Notes
Flow Sheet
A 59-year-old male client presents to the clinic reporting pain in the right great toe. The client says that the pain feels like it is another attack of gout, which he has had on 2 other occasions in the last 4 months.
The client tells the nurses that the pain started about 9 days ago in the evening and that it got very painful and swollen shortly thereafter. In the past, the gout attacks have resolved without treatment after about 5 days, but the client reports that his condition has not
Which finding(s) in the client's health record should the nurse recognize places the client at a greater risk of developing gout? Select all that apply.
- A. Obesity
- B. Hypertension
- C. Drinks beer nightly
- D. Daily aspirin
- E. Type 2 diabetes mellitus
- F. Sleep apnea
- G. Ibuprofen for pain
Correct Answer: A,B,C,D,E,F
Rationale: Obesity, hypertension, alcohol consumption (especially beer), low-dose aspirin, type 2 diabetes mellitus, and sleep apnea are all associated with increased uric acid levels or decreased excretion, contributing to gout risk. Ibuprofen, smoking status, and osteoarthritis do not directly increase gout risk.