Nokea
History and Physical
Laboratory Results
Vital signs
The client is a 68-year-old with a history of diabetes, hypertension (HTN), coronary artery disease (CAD), and was recently diagnosed with end-stage renal disease (ERSD). She has been placed on hemodialysis three times a week for one month. She presents to the emergency department (ED) with fatigue, generalized weakness, muscle cramps, tingling sensation in her arms and legs, and lightheadedness following 3 days of Illness during which her husband reports she has complained of nausea and had a poor appetite and not able to go for her scheduled dialysis 2
On further assessment, the client reports that her doctor had recently started her on Lisinopril for blood pressure control but it "doesn't seem to help". She then complained of some chest discomfort. The client is moved to an ED room, and another set of vital signs is performed. Physician notified and orders received
Which of the following physician's orders requires priority attention from the nurse? Select all that apply.
- A. Basic metabolic panel
- B. Echocardiogram
- C. CT scan of abdomen
- D. Blood cultures times 2 sets
- E. Chest X-ray
- F. Place on a continuous cardiac monitor
- G. CBC
Correct Answer: E,F
Rationale: Chest X-ray and continuous cardiac monitoring are priorities to assess chest discomfort and potential arrhythmias in a client with CAD and hyperkalemia risk. Other orders are important but less urgent.
You may also like to solve these questions
A client with depression does not want to communicate with friends, uses television watching as a means of escaping responsibilities, and describes the inability to handle personal circumstances. Which coping strategy should the nurse include in the plan of care?
- A. Concentrate on and ventilate emotions when distressed.
- B. Shift attention from self to the needs and requests of others.
- C. Relax and reduce the amount of effort to solve the problem.
- D. Focus on small achievable tasks, not taxing problems.
Correct Answer: D
Rationale: Focusing on small achievable tasks can reduce feelings of overwhelm and improve self-efficacy in a client with depression. Ventilating emotions may exacerbate distress, shifting attention may neglect personal needs, and relaxation may perpetuate helplessness.
History and Physical
Nurse's Notes
Orders
The client is in the hospital after her house collapsed during a hurricane. She has been in the intensive care unit for 2 weeks and moved today to the surgical floor to continue monitoring her respiratory function and to complete intravenous antibiotic administration.
For each client statement, click to highlight the statement(s) below that require follow-up teaching by the nurse.
- A. This diagnosis means that I am crazy.'
- B. I can learn to manage my thoughts better through therapy.'
- C. I can use holistic approaches like meditation to help my symptoms.'
- D. Many people have the same response to a stressful situation as I am having right'
- E. I am at high risk for post-traumatic-stress disorder because I have acute stress disorder'
- F. I will probably need to be on medication for the rest of my life.'
Correct Answer: A,C,D,F
Rationale: Statements about being 'crazy,' typical stress responses, holistic approaches, and lifelong medication need clarification to address stigma, variability in trauma responses, and treatment plans.
History and Physical
The client is in the hospital after her house collapsed during a hurricane. She has been in the intensive care unit for 2 weeks and moved today to the surgical floor to continue monitoring her respiratory function and to complete intravenous antibiotic administration. Nurses' Notes
0900
Pain assessment completed. The client's pain is 2/10. The client requests sleeping medication for the night. She states that she has horrible thoughts and memories about the house collapsing all the time and that it is keeping her from falling asleep. She states, "I used to be so happy before all of this happened. Now I can't seem to get out of this funk I am in." The client would also prefer to be in a quieter area of the unit as she is currently by the nurses' station and hears talking and alarms constantly.
The client is in the hospital after her house collapsed during a hurricane. She has been in the intensive care unit for 2 weeks and moved today to the surgical floor to continue monitoring her respiratory function and to complete intravenous antibiotic administration. The nurse engages the client in conversation about her feelings and some of her coping mechanisms. Click to specify which client statement or behavior is most likely associated with each of the listed defense mechanisms.
- A. The client discusses moving to Hawaii instead of returning to rebuild her house. (Fantasy)
- B. The client seems unemotional when talking about needing to rebuild her house. (Isolation)
- C. The client states that she sometimes forgets why she is in the hospital. (Suppression)
- D. The client is frightened that the hospital will burn down. (Denial)
Correct Answer: A,B,C,D
Rationale: Fantasy (Hawaii move) escapes reality, isolation (unemotional) separates emotions, suppression (forgetting hospitalization) avoids distress, and denial (hospital fire fear) projects trauma.
A client is admitted to the hospital with suicidal ideation. When completing the health history and admission assessment interview, which client comment is most important for the nurse to document?
- A. I just feel like my life is filled with emptiness.'
- B. I have three firearms locked in a safe at home.'
- C. My daughter is the only reason I keep trying.'
- D. My panic attacks happen once every month.'
Correct Answer: B
Rationale: Access to firearms is a significant risk factor for suicide, making it critical to document. Other comments are relevant but less urgent.
A client with benign prostatic hyperplasia (BPH) is preparing for discharge following a transurethral needle ablation (TUNA). Which information should the nurse include in the discharge instructions?
- A. Use an incentive spirometer.
- B. Monitor the urinary stream for the decrease in output.
- C. Report when hematuria becomes pink-tinged.
- D. Restrict physical activities.
Correct Answer: C
Rationale: Reporting pink-tinged hematuria is critical to monitor for complications post-TUNA. Spirometry, urinary stream monitoring, and activity restriction are not specific to TUNA discharge.