Which of the following parent statements indicate a correct...

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 parent statements indicate a correct understanding? Select all that apply.

A. A low-fat diet will help normalize my child's stool.'
B. I will encourage my child to get regular exercise.'
C. I will make sure that my child receives the flu vaccine each year.'
D. My child should perform daily breathing exercises, even if there are no symptoms.'
E. My child will require lifelong vitamin supplementation.'
F. The pancre-lipase capsules can be opened and sprinkled on food.'

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

Rationale: Exercise , flu vaccine , daily breathing exercises , vitamin supplementation , and sprinkling pancre-lipase are correct. A low-fat diet is incorrect; a high-calorie, high-fat diet is needed for cystic fibrosis.

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-BarrÃ© 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 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 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

The client is most likely experiencing ....... and is at risk for.......

A. Osteomyelitis
B. Rhabdomyolysis
C. Sickle acute cell pain episode
D. Sepsis
E. Ischemic organ damage
F. Compartment syndrome

Correct Answer: C,E

Rationale: Severe pain and tachycardia suggest a sickle cell pain episode , with risk for ischemic organ damage due to vaso-occlusion.

The nurse is caring for an infant in the clinic.
Nurses' Notes Clinic Visit: Age 4 Months
0800: The infant is playing with the hands and feet and making cooing sounds. The infant smiles and laughs appropriately when the caregiver provides a toy. No evidence of Moro, tonic, or rooting reflexes noted. The infant has weak muscle tone in the neck and does not hold the head up independently.
Clinic Visit: Age 6 Months
0930: The infant does not have head control. The caregiver reports that the infant babbles but does not use words or call the parent by any name. The infant does not point at desired objects. The caregiver also reports that the infant has begun to act afraid of unfamiliar people

The nurse recognizes that the 6-month-old infant who ........ should be evaluated for........

A. Does not use words
B. Lacks control of the head
C. Does not point at desired objects
D. Cerebral palsy
E. Hearing Impairment
F. Autism spectrum disorder

Correct Answer: B,D

Rationale: Lack of head control at 6 months is concerning for cerebral palsy , as it indicates delayed motor development.

The nurse should notify the health care provider about which client data?

A. Miosis of bilateral pupils
B. Most recent reticulocyte count
C. No bowel movement in 2 days
D. Pain rated as 2 on a scale of 0-10

Correct Answer: A

Rationale: Miosis suggests opioid overdose, requiring immediate provider notification.