Nokea
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 action should the nurse perform first?
- A. Administer lorazepam, haloperidol, and diphenhydramine
- B. Direct other clients away from the area
- C. Offer the client distraction activities
- D. Place the client in 4-point restraints
- E. Request additional staff presence
Correct Answer: E
Rationale: Requesting staff presence ensures safety for de-escalation or intervention in an acute psychotic episode.
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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
Click to highlight below the 4 findings that require immediate follow-up.
- A. 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
- B. The client appears restless with frequent position changes and facial grimacing
- C. Vital signs: RR 24, SpO2 95% on room air; breath sounds are clear bilaterally
- D. 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
- E. The client vomited 30 mL of clear liquid
- F. The client has multiple, tender, bony points
- G. The client voided 50 mL of clear, amber-colored urine
Correct Answer: A,B,D,F
Rationale: Severe pain , distress signs , tachycardia , and bony tenderness indicate a sickle cell crisis, requiring urgent management.
The nurse is contacting a client at 28 weeks gestation to review laboratory results and schedule a follow-up prenatal visit. Laboratory Results Laboratory Test and Reference Range 12 Weeks Gestation 26 Weeks Gestation 28 Weeks Gestation
WBC (prostent) 5,000-1多份 (5.0-15.0 × 10°/L) 8,900/mm3 (8.9 × 10°/L) 16,500 /mm° (16.5 × 10%/L)
Hemoglobin (pregnant) 11-16 g/dL (110-160 g/L) 13 g/dL (130 g/L) 10.8 g/dL (108 g/L) Hematocrit (pregnant) 33%-47% (0.33-0.47) 39% (0.39) 32% (0.32)
Chlamydia Negative Positive Negative Hemoglobin A1c 4.0%-5.9% 5.1%
1-hour oral glucose challenge test <140 mg/dL (7.8 mmol/L) 175 mg/dL (9.7 mmol/L)
3-hour oral glucose tolerance test Fasting: <110 mg/dL (6.1 mmol/L) 1 hour: <180 mg/dL (10.0 mmol/L) 2 hour: <140 mg/dL (7.8 mmol/L 3 hour: <70-115 mg/dL (<6.4 mmol/L) Fasting: 115 mg/dL (6.4 mmol/L) 1 hour: 205 mg/dL (11.4 mmol/L) 2 hour: 162 mg/dL (9.0 mg/dL) 3 hour: 135 mg/dL (7.5 mg/dL)
Which 3 instructions should the nurse include in the teaching?
- A. Avoid including carbohydrates in the diet
- B. Draw up NPH insulin into a syringe first and then lispro insulin in the same syringe
- C. Eat a meal 60 minutes after taking the morning insulin dose
- D. Inject insulin into the subcutaneous tissue in the abdomen
- E. Monitor for symptoms such as headache, trembling, hunger, or sweating
- F. Perform fetal kick counts daily to monitor the well-being of the fetus
Correct Answer: D,E,F
Rationale: Abdominal injection , monitoring hypoglycemia symptoms , and fetal kick counts are key for gestational diabetes management.
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 of the following symptoms are consistent with schizophrenia? Select all that apply.
- A. Disorganized speech
- B. Flat affect
- C. Laughing for no apparent reason
- D. Loss of interest in pleasurable activities
- E. Self-care deficit
Correct Answer: A,B,C,D,E
Rationale: Schizophrenia symptoms include disorganized speech , flat affect , inappropriate laughter , anhedonia , and poor self-care .
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 assisting the registered nurse with caring for a client who is at 36 weeks gestation. History and Physical Vital Signs
General - Client is gravida 2 para 1 at 36 weeks gestation; reports a throbbing headache rated as / on a scale of 0-10, blurred vision, and epigastric pain; client states that she took 1000 mg of acetaminophen 2 hours ago with no relief, medical history includes seasonal allergies and exercise-induced asthma
Neurological -Patellar deep tendon reflexes 2+ bilaterally, clonus absent
Cardiovascular -Heart tones normal; facial edema noted; +2 pitting edema in bilateral upper extremities; +3 pitting edema in bilateral lower extremities
Gastrointestinal -Client reports fetal movement, no contractions noted; soft uterine resting tone on palpation
Genitourinary -Cervical examination: 1 cm dilated, 0% effaced, -3 fetal station, cephalic fetal presentation, amniotic membranes intact; cesarean birth 5 years ago at 40 weeks gestation for breech fetal presentation, resulting in delivery of healthy newborn
For each potential intervention, click to specify if the Intervention is indicated or not indicated for the care of the client.
- A. Initiate seizure precautions
- B. Encourage frequent ambulation
- C. Start a magnesium sulfate infusion
- D. Prepare to administer antihypertensives
Correct Answer: A,C,D
Rationale: Seizure precautions , magnesium sulfate , and antihypertensives are indicated for preeclampsia with severe features. Ambulation is not prioritized due to risk of falls.