Which client statement would indicate that the client requir...

The nurse is caring for a 21-year-old client.
Nurses' Notes History and Physical Vital Signs
Emergency Department
0800: The client comes to the emergency department due to fear of having a heart attack. The client reports, "I was taking the bus home from work when my chest started feeling really tight. I'm lucky my friend was there and able to help me get to the hospital. What if my friend is not there next time?" The client describes experiencing similar episodes recently at random places and times and worries about when or where the next attack will occur

Which client statement would indicate that the client requires additional therapy to appropriately cope with the panic disorder?

A. I have realized that even though my panic attacks are under control, I will eventually need to be tapered off the alprazolam.'
B. I purchased a watch that alerts me when my heart or respiratory rate increases so I can begin breathing exercises to calm myself.'
C. My support group has been helping me to identify when my thoughts are not realistic so I can talk myself out of feelings of panic.'
D. Taking the bus to work has been a trigger for me so my boss is letting me work from home.'

Correct Answer: D

Rationale: Avoiding triggers like the bus without coping strategies indicates reliance on avoidance, requiring further therapy.

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 2 prescriptions the nurse should implement first.

A. Administer morphine
B. Administer hydroxyurea PO
C. Apply moist heat to knees
D. Encourage incentive spirometer
E. Continuous IV fluids
F. Record strict intake and output

Correct Answer: A,E

Rationale: Morphine and IV fluids are prioritized to relieve pain and improve hydration in a sickle cell crisis.

The nurse is caring for a 68-year-old client who is brought to the emergency department due to confusion.
History and Physical Body System Findings
General- Client's adult child reports the confusion started this morning, following 3 days of fever and productive cough; medical history includes small bowel resection 10 days ago, chronic heart failure, and coronary artery disease
Neurological- Client is drowsy and oriented to person only, but intermittently agitated Integumentary- Small abdominal surgical incision is present over lower left quadrant, edges are well approximated, and no redness or drainage is noted
Pulmonary- Vital signs are RR 24 and SpO 90% on room air; labored breathing is observed, and crackles and diminished breath sounds are auscultated over right lower chest; client is expectorating yellow sputum; history includes smoking a pack of cigarettes daily for the past 40 years
Cardiovascular- Vital signs are T 102.9 F (39.4 C), P 110, and BP 110/70; S1 and S2 are heard on auscultation; bilateral lower extremity edema is 1+; ECG shows sinus tachycardia
Gastrointestinal- Normoactive bowel sounds are auscultated; client's last bowel movement was 1 day ago
Genitourinary- Client voided concentrated yellow urine

Click to highlight below the findings that require follow-up by the nurse.

A. 3 days of fever and productive cough
B. crackles and diminished breath sounds are auscultated over right lower chest
C. bilateral lower extremity edema is 1+
D. client's last bowel movement was 1 day ago

Correct Answer: A,B

Rationale: Fever with cough and crackles indicate pneumonia, requiring immediate intervention.

For each potential intervention, click to specify if the intervention is indicated or contraindicated for the care of the client.

A. Encourage the use of positive self-talk
B. Ask the client about any recent life stressors
C. Assist the client to recognize physical symptoms of anxiety
D. Encourage the client to spend time alone when feeling anxious
E. Reinforce abdominal breathing exercises to use at the onset of anxiety

Correct Answer: A,B,C,E

Rationale: Positive self-talk , identifying stressors , recognizing symptoms , and breathing exercises manage panic disorder. Isolation may worsen anxiety.

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 75-year-old female client. Nurses' Notes Laboratory Results Diagnostic Results Emergency Department
The client is transferred to the emergency department from a skilled nursing facility for a 3-day history of left lower quadrant abdominal pain rated 8 on a scale of 0-10, loss of appetite, and nausea. Although the client has a history of chronic constipation, she has had 2 or 3 loose stools daily for 1 week. The client reports tenderness on deep palpation of the left lower quadrant. There is an area of blanchable redness on the coccyx. The stool is positive for occult blood.
The client has residual left-sided weakness from an ischemic stroke 2 years ago and ambulates with a walker. The client reports falling several times in the past 6 months; the last fall was 3 weeks ago No ecchymosis or injuries are noted. The client had a hysterectomy and salpingo-oophorectomy for uterine fibroids 20 years ago. Vital signs are T 100 F (37.8 C), P 98, RR 17, BP 126/68, and SpOz 97% on room air.
Medical-Surgical Unit: 4 Days Later
The client continues to experience left lower quadrant pain, decreased appetite, and nausea. Today, she developed chills. Stool frequency has not increased. Severe tenderness is noted in the left lower quadrant, and a mass is palpable. Vital signs are T 101.3 F (38.5 C), P 112, RR 17, BP 110/80, SpO, 97% on room air.

Click to highlight below the findings that are most concerning at this time.

A. The client is transferred to the emergency department from a skilled nursing facility for a 3-day history of left lower quadrant abdominal pain rated 8 on a scale of 0-10, loss of appetite, and nausea.
B. Although the client has a history of chronic constipation, she has had 2 or 3 loose stools daily for 1 week.
C. The client reports tenderness on deep palpation of the left lower quadrant. There is an area of blanchable redness on the coccyx. The stool is positive for occult blood.
D. The client has residual left-sided weakness from an ischemic stroke 2 years ago and ambulates with a walker.
E. The client reports falling several times in the past 6 months; the last fall was 3 weeks ago. No ecchymosis or injuries are noted.
F. The client had a hysterectomy and salpingo-oophorectomy for uterine fibroids 20 years ago. Vital signs are T 100 F (37.8 C), P 98, RR 17, BP 126/68, and SpO2 97% on room air.

Correct Answer: A,C

Rationale: Severe abdominal pain with nausea and tenderness with occult blood suggest acute diverticulitis, requiring urgent evaluation.