Nokea
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.
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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.
Which of the following complications is the newborn at increased risk for based on the maternal hist Select all that apply.
- A. Brachial plexus injury
- B. Cephalohematoma
- C. Hypoglycemia
- D. Neonatal sepsis
- E. Polycythemia
Correct Answer: A,C,E
Rationale: Gestational diabetes and smoking increase risks for brachial plexus injury , hypoglycemia , and polycythemia .
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 43-year-old client.
Nurses' Notes Vital Signs
Emergency Department
0800: A 43-year-old client comes to the emergency department due to lower back pain and bilateral leg weakness. The client reports that the weakness began 3 days ago in the feet and has gradually worsened. The client sought treatment today after becoming "so weak that I fell while walking" and noticing new hand weakness and difficulty swallowing. Back pain radiates down both legs and is rated as 5 on a scale of 0-10. The client recently recovered from an illness with flu-like symptoms. The client reports a history of hypertension and takes no medications. Assessment of the lower extremities reveals muscle strength of 2/5 and decreased sensation to pinprick. Achilles tendon and patellar reflexes are decreased
For each finding below, click to specify if the finding is consistent with the disease process of Guillain-Barré syndrome, ischemic brain stroke, or lumbar disk herniation.
- A. Radiating back pain
- B. Difficulty swallowing
- C. Recent viral infection
- D. Ascending muscle weakness
Correct Answer: A,B,C,D
Rationale: Radiating pain is typical of disk herniation, swallowing issues occur in GBS and stroke, viral history and ascending weakness are specific to GBS.
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 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. 1400: The newborn is delivered via forceps-assisted vaginal birth at
1400. The newborn was immediately placed in skin-to-skin contact with the mother, dried, and stimulated. Apgar scores are 7 at 1 minute and 9 at 5 minutes
1405: Newborn vital signs are T 97.3 F (36.3 C), P 156, and RR 52.
1415: Newborn weight is obtained. The newborn is 9 lb 15 oz (4500 g). The maternal client is assisted to latch the newborn onto the breast.
1430: Slight bruising to the scalp is noted where forceps were applied. Newborn vital signs are T 97.2 F (36.2 C), P 160, RR 55, and SpO 95% on room air.
In addition to a maternal history of gestational diabetes mellitus, the newborn's...... and ..... place the newborn at increased risk for hypoglycemia.
- A. Bruising
- B. Birth weight
- C. Temperature
- D. Apgar scores
- E. Gestational age
Correct Answer: B,C
Rationale: Macrosomia and hypothermia exacerbate hypoglycemia risk in gestational diabetes.