Nokea
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 clinical findings require further follow-up? Select all that apply.
- A. Crepitus noted over the right clavicle
- B. Cyanosis of the hands and feet
- C. Heart rate of 165/min while crying
- D. Jitteriness
- E. Moro reflex is decreased in the right extremity
- F. Respirations of 60/min
Correct Answer: A,D,E
Rationale: Crepitus suggests fracture, jitteriness indicates hypoglycemia, and decreased Moro reflex may indicate nerve injury.
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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 of the following client findings are consistent with a cystic fibrosis exacerbation? Select all that apply.
- A. Blood-tinged sputum
- B. Greasy, bulky stools
- C. Paroxysmal coughing
- D. SpO2 of 87% on room air
- E. Temperature of 101.7 F (38.7 C)
Correct Answer: A,B,C,D,E
Rationale: Cystic fibrosis exacerbations often present with increased respiratory symptoms (A, C, D), fever , and malabsorption issues due to pancreatic insufficiency.
Which of the following statements by the client indicate that teaching has been effective? Select all that apply.
- A. I plan to take a 20-minute brisk walk twice daily.'
- B. I should bake or broil foods instead of frying them.'
- C. I should eat white bread instead of multigrain bread.'
- D. I will avoid straining when passing a bowel movement.'
- E. I will drink at least 1 L (1000 mL) of fluid daily.'
Correct Answer: A,B,D
Rationale: Exercise , healthy cooking , and avoiding straining prevent diverticulitis recurrence. White bread is less beneficial than high-fiber foods, and 1 L fluid is insufficient.
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
For each finding below, click to specify if the finding is consistent with the disease process of hyperthyroidism, myocardial infarction, or panic disorder.
- A. Diaphoresis
- B. Trembling hands
- C. Heart palpitations
- D. Shortness of breath
Correct Answer: A,B,C,D
Rationale: Diaphoresis , palpitations , and shortness of breath occur in all three. Trembling hands are specific to hyperthyroidism and panic disorder.
The nurse is caring for a 55-year-old client in the clinic.
History and Physical
Body System
Findings: General - The client reports cramping pain in the left calf that has worsened over the past year. The pain is precipitated by walking and is partially relieved with rest. The client reports difficulty walking more than 3 blocks. Height: 72 in (182.9 cm), weight: 250 lb (113.4 kg), BMI: 33.9 kg/m?
Pulmonary- Vital signs are RR 16, SpO, 97% on room air. Client reports smoking 1 pack of cigarettes daily for the past 35 years. Breath sounds are mildly decreased throughout with mild prolonged expiration. Client has a history of chronic obstructive pulmonary disease.
Cardiovascular- Vital signs are T 98.8 F (37.1 C), P 82, BP 146/82. S1 and S2 heard on auscultation. The left lower extremity (LLE) is cooler to touch than the right and appears shiny with sparse hair. LLE pulses: femoral 2+, popliteal 1+, posterior tibia 1+, dorsalis pedis audible with Doppler. LLE capillary refill >3 sec. Client has a history of hypertension.
Gastrointestinal- Client is obese. No tenderness, guarding, masses, bruits, or hepatosplenomegaly.
Which of the following statements should the nurse include in the teaching? Select all that apply.
- A. Elevate your legs several times during the day to relieve pain.'
- B. Incorporate more fruits and vegetables into your diet.'
- C. Inspect your feet daily for any wounds.'
- D. Use a heating blanket if your legs get cold.'
- E. Walk each day until you have leg pain, rest for 10 minutes, and then continue walking.'
Correct Answer: B,C,E
Rationale: Healthy diet , foot inspections , and supervised walking are appropriate. Elevation is for venous issues, and heating blankets risk burns in poor perfusion.
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.
The nurse recognizes the client has most likely developed .........anticipate assisting with.........
- A. An abscess
- B. Colon cancer
- C. Clostridiodes difficile infection
- D. Collecting a stool culture
- E. Preparing the client for a colostomy
- F. Obtaining a repeat CT scan of the abdomen
Correct Answer: A,F
Rationale: A palpable mass and fever suggest an abscess , requiring a CT scan for confirmation.