Nokea
The nurse is caring for a 68-year-old client in the emergency department.
History Physical Vital Signs
Admission: The client comes to the emergency department with progressively worsening back pain that began 3 weeks ago. The pain has become significantly worse over the past 12 hours. Pain level is rated as 8 on a scale of 0-10. The client was recently diagnosed with prostate cancer and has had a poor response to treatment. This morning, the client had trouble walking and reports decreased sensation in the feet. The client also reports mild nausea, difficulty urinating, decreased urinary sensation, and no bowel movement in the past 3 days
Which client statement requires immediate follow-up with the health care provider?
- A. Are my feet covered? I cannot feel them anymore.'
- B. I cannot finish my lunch today; my abdomen feels so distended.'
- C. I have been so exhausted since my last chemotherapy treatment.'
- D. When is my next dose of pain medicine? My pain is a 10 out of 10 .'
Correct Answer: A
Rationale: Loss of sensation in the feet suggests worsening spinal cord compression, requiring urgent provider notification.
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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 caring for an 88-year-old client with pneumonia.
Nurses' Notes Vital Signs Medical-Surgical Unit
0800: The client has dyspnea that worsens on exertion, a productive cough, and fever. Crackles are heard in the bilateral lower lung lobes.
1000: The client is restless, coughs frequently, and struggles to breathe.
The nurse should first Select... to Select... ...
- A. Elevate the head of the bed
- B. Administer albuterol nebulizer
- C. Assist the client to drink clear fluids
- D. Thin secretions
- E. Increase lung expansion
- F. Relax bronchial smooth muscles
Correct Answer: A,E
Rationale: Elevating the head of the bed promotes lung expansion to improve breathing in pneumonia.
The nurse is caring for a 63-year-old client.
Progress Notes
Emergency department
1 week ago: The client is admitted to the hospital with dyspnea, orthopnea, and bilateral leg swelling. The client has hypertension, heart failure, and chronic kidney disease. Medications include furosemide, hydrochlorothiazide, lisinopril, and metoprolol.
Clinic visit
Today: The client was recently discharged from the hospital after treatment for acute heart failure. Symptoms improved after treatment with diuretics. Today, the client reports new-onset muffled hearing and difficulty understanding speech. Examination shows bilateral hearing loss.
Which medication should the nurse clarify with the health care provider?
- A. Furosemide
- B. Hydrochlorothiazide
- C. Lisinopril
- D. Metoprolol
Correct Answer: A
Rationale: Furosemide is associated with ototoxicity, which may cause hearing loss, requiring clarification.
The nurse is caring for a 68-year-old client in the emergency department.
History Physical Vital Signs
Admission: The client comes to the emergency department with progressively worsening back pain that began 3 weeks ago. The pain has become significantly worse over the past 12 hours. Pain level is rated as 8 on a scale of 0-10. The client was recently diagnosed with prostate cancer and has had a poor response to treatment. This morning, the client had trouble walking and reports decreased sensation in the feet. The client also reports mild nausea, difficulty urinating, decreased urinary sensation, and no bowel movement in the past 3 days
The nurse should prioritize interventions for........... to prevent .........
- A. Hypercalcemia
- B. Spinal cord compressions
- C. Syndrome of inappropriate antidiuretic hormone
- D. Seizure
- E. Paralysis
- F. Dysrhythmias
Correct Answer: B,E
Rationale: Spinal cord compression interventions aim to prevent paralysis due to nerve damage.
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 prescription should the nurse implement first?
- A. Administer albuterol via a metered-dose inhaler
- B. Administer hypertonic saline via a nebulizer
- C. Contact respiratory therapy to initiate chest physiotherapy
- D. Reinforce teaching on how to use a positive expiratory pressure device
Correct Answer: A
Rationale: Albuterol is prioritized to relieve acute bronchospasm and improve airflow in respiratory distress.