Which condition does the nurse suspect?

The nurse is caring for a 12-year-old client.
History and Physical Vital Signs Body System Findings
General- The client has a 2-day history of decreased appetite, nausea, fatigue, and headaches, the client had a "sore throat" 2 weeks ago that resolved without treatment; BMl is in the 65th percentile
Eye, Ears, Nose, and Throat (EENT)- Periorbital edema; no changes in vision
Pulmonary- Lung sounds clear bilaterally; no increased work of breathing; no cough Cardiovascular- S1 and S2 heard on auscultation; no murmur auscultated; 3+ bilateral lower extremity edema is noted
Gastrointestinal- Bowel sounds present, no masses or tenderness felt Musculoskeletal No joint pain or swelling
Genitourinary- Decreased urination; dark, cola-colored urine

A. Acute postinfectious glomerulonephritis
B. Hemolytic uremic syndrome
C. Rhabdomyolysis
D. Urinary tract infection

Correct Answer: A

Rationale: Cola-colored urine, edema, and recent infection point to acute postinfectious glomerulonephritis.

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 of the following findings require immediate follow-up? Select all that apply

A. Chest tightness
B. Flat affect
C. Heart palpitations
D. Minimal eye contact
E. Shortness of breath
F. Weight loss

Correct Answer: A,C,E

Rationale: Chest tightness , palpitations , and shortness of breath suggest a panic attack or cardiac issue, requiring urgent evaluation.

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"

Click to highlight below the assessment findings that require immediate follow-up?

A. 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
B. Alert and oriented to person, place, and time; no neurologic deficits
C. Vital signs: RR 30, SpO2 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
D. 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 seconds; mild finger clubbing noted
E. 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'

Correct Answer: A,C,D,E

Rationale: Findings A, C, D, and E indicate urgent issues: shortness of breath with a history of cystic fibrosis , low oxygen saturation and respiratory distress , fever and tachycardia , and malabsorption symptoms require immediate intervention.

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 indicate a correct understanding of the health care provider's teaching? Select all that apply.

A. I can start this medication now while planning to stop smoking cigarettes soon.'
B. I may experience a disturbance in my sleep and have unusual dreams.'
C. I may lose some weight with smoking cessation.'
D. I should call my health care provider if I notice a significant change in my mood.'
E. I should not use any nicotine replacement while taking this medication.'

Correct Answer: A,B,D,E

Rationale: Varenicline can start before quitting , cause sleep issues , require mood monitoring , and is not combined with nicotine replacement . Weight loss is not guaranteed.

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

Which of the following findings are clinical manifestations of preeclampsia? Select all that apply.

A. Epigastric pain
B. Facial edema
C. High blood pressure
D. Proteinuria
E. Throbing headache
F. Visual disturbances

Correct Answer: A,B,C,D,E,F

Rationale: Preeclampsia manifests with epigastric pain , edema , hypertension , proteinuria , headaches , and visual disturbances .

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.