Which of the following statements by the client's parent ind...

Nurses' Notes
Initial Clinic Visit
1100:
The client has experienced enuresis at night for the past 2 weeks and frequently requests to use the
bathroom while at school. The client was previously toilet trained with no nighttime bed wetting for 6 months;
the client recently relocated to a new home and school where the client lives with parents.
The parent reports that the client has recently demonstrated fatigue, irritability, and multiple behavioral
outbursts that resemble past temper tantrums. The client frequently reports feeling thirsty. No dysuria or
urinary hesitancy is reported.
Weight and height were in the 40th percentiles at the previous visit a year ago. Growth charts today show
the client's weight in the 20th percentile and height in the 40th percentile.
The client appears tired and irritable. Dry mucous membranes are noted with no increased work of
breathing. The lungs are clear to auscultation bilaterally. No cardiac murmur is heard.

Which of the following statements by the client's parent indicates a correct understanding of the teaching about management for type 1 diabetes mellitus? Select all that apply

A. I may need to administer insulin more frequently when my child is ill
B. Insulin requirements will change as my child grows
C. Insulin should be injected deeply enough to reach the muscle
D. Overnight social events should be avoided to prevent changes in my child's routine
E. Proper diet and exercise can eliminate the need for insulin during adulthood.

Correct Answer: A,B

Rationale: Clients with type 1 diabetes mellitus (DM) have impaired insulin production due to autoimmune destruction of pancreatic beta
cells. Because clients with type 1 DM do not produce insulin, lifelong insulin replacement is required. Insulin requirements
will change with growth and development
Insulin requirements may increase because stressful events (eg, illness) cause blood glucose levels to rise. When the
client is ill, the parent should be instructed to notify the health care provider, monitor blood glucose levels closely, test the urine
for ketones, increase insulin administration per sliding scale, and monitor for signs of dehydration

Nurses' Notes
Outpatient Clinic
Initial
visit
The child recently started attending a new preschool and hit a teacher during lunch. The parent says,
"My
child has never been aggressive before but has always been particular about food."
The client was born at full term without complications and has no significant medical history. The child
started babbling at age 6 months, and the parent reports that the first words were spoken around age 12
months. The client then became quiet and "obsessed" with stacking blocks and organizing toys by color.
The child can kick a ball, draw a circle, pedal a tricycle, and now says two-word phrases. Vitals signs are
normal, and the client is tracking adequately on growth curves.
During the evaluation, the child sits in the corner of the room playing with blocks. The client does not follow
the parents gaze when the parent points to toys in the office. The child begins screaming and rocking back
and forth when the health care provider comes near.
Laboratory Results
Laboratory Test and
Reference Range
1030
Glucose (random)
71-200 mg/dL
(3.9-11.1 mmol/L)
110 mg/dL (6.1 mmol/L)
Sodium
136-145 mEq/L
(136-145 mmol/L)|
133 mEq/L (133 mmol/L)|
Potassium
3.5-5.0 mEq/L
(3.5-5.0 mmol/L)
4.5 mEq/L (4.5 mmol/L)
B-type natriuretic peptide
<100 pg/mL
(<100 ng/L)
640 pg/mL (640 ng/L)
Diagnostic Results
Chest X-ray
1030:Mild cardiomegaly
Echocardiogram
1100:Mild left ventricular hypertrophy with left ventricular ejection fraction of 30%

The nurse suspects the client is experiencing acute decompensated heart failure. Which of the following findings are consistent with this condition? Select all that apply.

A. Crackles with auscultation
B. Decreased capillary oxygen saturation
C. Elevated b-type natriuretic peptide
D. Left ventricular ejection fraction 30%
E. Lower extremity pitting edema

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

Rationale: The findings all support the diagnosis of acute decompensated heart failure (ADHF):

Crackles with auscultation: Indicative of pulmonary congestion due to fluid overload.

Decreased capillary oxygen saturation: Reflects impaired gas exchange from fluid in the lungs.

Elevated B-type natriuretic peptide (BNP): A level of 640 pg/mL is significantly elevated; BNP is released when the ventricles are stretched due to increased fluid volume.

Left ventricular ejection fraction of 30%: Normal is 55–70%. This reduced EF confirms systolic dysfunction, common in ADHF.

Lower extremity pitting edema: A classic sign of volume overload in right-sided or total heart failure.

History and Physical
Body System
Findings
General
Client reports a 1-week history of general malaise, fever and chills, night sweats, fatigue, and
poor appetite. Client has poorly controlled hypertension, hypercholesterolemia, and mitral
valve prolapse and regurgitation.
Eye, Ear, Nose, and
Throat (EENT)
Poor dental hygiene. Client reports having 2 teeth extracted 3 weeks ago.
Pulmonary
Vital signs are RR 18 and SpO, 96% on room air. Lungs are clear to auscultation bilaterally.
Cardiovascular
Vital signs are T 100.4 F (38 C), P 105, and BP 140/82. Sinus tachycardia with occasional
premature ventricular contractions on cardiac monitor. S1 and S2 heard on auscultation with
loud systolic murmur at the apex. Peripheral pulses 2+; no edema noted.
Integumentary
Small, erythematous macular lesions on both palms. Thin, brown longitudinal lines on several
nail beds.

The nurse is preparing to administer the first dose of the prescribed IVPB antibiotic. Which 2 actions are most appropriate for the nurse to perform prior to initiating the infusion?

A. Administer a dose of PRN acetaminophen
B. Ask about the client's medication allergies
C. Ensure that prescribed blood cultures have been obtained
D. Ensure that the prescribed echocardiography has been obtained
E. Reschedule the antibiotic dose until the central venous catheter is in place

Correct Answer: B,C

Rationale: Antibiotic therapy is a critical component of treatment for clients with infective endocarditis (E). Before administering IV
antibiotics, the nurse should first obtain blood cultures to identify the infectious organism. Broad-spectrum antibiotics are
started initially. Targeted antibiotic therapy can be administered once the blood cultures identify the culprit organisms and their
antimicrobial susceptibilities. Before starting any medication, the nurse should ask about the client's medication allergies to
identify contraindications to therapy

History
Emergency Department
Admission: The client is brought to the emergency department for psychiatric evaluation after being found on the
roof of a seven-floor office tower screaming, "I am going to jump! Life is not worth living anymore!" The
client admits having attempted to jump off the building and wishes the police had not intervened. The
client reports that thoughts of self-harm have increased in intensity since a divorce 2 months ago. The
client's thoughts of self-harm are intermittent, with no reports of suicidal thoughts at the present time.
The client reports losing 10 pounds in the past month without trying, difficulty concentrating on tasks,
and feeling tired most of the day. No history of violence or trauma. The client reports recurring feelings
of worthlessness but no auditory/visual hallucinations or homicidal ideations.
Medical history includes seizures, but the client has not been taking prescribed levetiracetam. The client
reports smoking 1 pack of cigarettes per day for the past 3 years.
Vital signs: T 97.2 F (36.2 C), P 100, BP 153/70, RR 19

Select below the 4 findings that indicate the client is at risk for suicidal ideation

A. losing 10 pounds in the past month
B. feeling tired most of the day
C. has not been taking prescribed levetiracetam
D. difficulty concentrating on tasks
E. recurring feelings of worthlessness
F. smoking 1 pack of cigarettes per day for the past 3 years

Correct Answer: A,B,D,E

Rationale: When caring for a client in a state of crisis, the nurse should monitor for suicidal ideation. The nurse should consider the
client's demographics, mental and physical health history, family history of suicide, previous suicide attempts, and protective
factors (eg, support system, coping skills). Factors that increase the client's risk for suicide include:
• Previous attempted suicide (eg, jumping off a building)
• Thoughts, intent, or plan to self-harm
• History of substance use (eg, cocaine, marijuana)
• Significant or sudden life loss, change, or stressor (eg, divorce)
• Mental health disorder (eg, depression)
• Symptoms of severe depression (eg, weight loss, difficulty concentrating, fatigue, feelings of worthlessness)

For each finding below, click to specify if the finding is consistent with the disease process of infective endocarditis, pericarditis, or pneumonia. Each finding may support more than one disease process.

A. New or worsening cardiac murmurs
B. Muffled heart sounds on auscultation
C. Splinter hemorrhages on the nail beds
D. Presence of flu-like symptoms and fever
E. Substernal pain that is aggravated by inspiration

Correct Answer:

Rationale: Infective endocarditis occurs when an infectious organism forms a vegetation on a heart valve (interior of the heart). Clients
often have nonspecific symptoms of infection such as fever, flu-like symptoms (myalgia, arthralgia), and malaise.
Vegetation on a heart valve makes the valve dysfunctional, creating a new or worsening cardiac murmur. Pieces of
endocardial vegetation can break off, forming microemboli that travel through the arteries to end-capillaries and block blood
flow (eg, splinter hemorrhages on the nail beds), and cause erythematous macular lesions on the palms or soles (Janeway
lesions).
Acute pericarditis is inflammation of the membranous sac surrounding the exterior of the heart (pericardium), which often
causes an increased fluid in the pericardial cavity (ie, pericardial effusion). If pericardial effusions accumulate rapidly or are
very large, they may compress the heart, altering the mechanics of the cardiac cycle (ie, cardiac tamponade). Clinical
manifestations of pericarditis include muffled heart sounds on auscultation, presence of flu-like symptoms and fever, and
substernal pain that is aggravated by inspiration (ie, pleuritic chest pain). Pericardial friction rub, a superficial scratching or
squeaky sound, may be present, but cardiac murmurs are not present (no valve involvement) and embolic phenomena are
uncommon.
Pneumonia is an infection in the lungs that results in the production of cellular debris and purulent secretions that obstruct the
alveoli and prevent adequate oxygenation. Clinical manifestations include the presence of flu-like symptoms and fever,
pleuritic chest pain, tachycardia, low capillary oxygen saturation (SpO2), crackles, and productive cough with purulent
sputum.

The nurse is caring for a 64-year-old client.
History and Physical
Body System, Findings
General ,
The client reports a 24-hour history of blurred vision and redness in the left eye with a left-sided headache.
This evening, the client developed acute, severe pain in the left eye accompanied by occasional nausea and
vomiting. The client reports no use of systemic or topical eye medications. Medical history includes
osteoarthritis and hypercholesterolemia.
Eye, Ear, Nose, and Throat (EENT),
The client wears eyeglasses to correct farsighted vision. Right eye: pupil 2 mm and reactive to light,
conjunctiva clear. Left eye: pupil 4 mm and nonreactive to light with red conjunctiva. Bilateral lens opacity is noted.
Pulmonary,
Vital signs are RR 20 and SpO, 96% on room air. The lungs are clear to auscultation bilaterally.
Cardiovascular,
Vital signs are T 99 F (37.2 C), P 88, and BP 140/82.
Psychosocial,
The client reports a great deal of emotional stress following the recent death of the client's spouse that is accompanied by lack of sleep, poor appetite, and a 7.9-lb (3.6-kg) weight loss within the past month. The client takes diphenhydramine for sleep.

The practical nurse is assisting the registered nurse with preparing the client's plan of care. Which of the following interventions are appropriate to include in the plan of care? Select all that apply.

A. Administer mannitol IV
B. Administer ondansetron IV
C. Implement fall precautions
D. Instruct the client to avoid blowing the nose
E. Place a patch over the client's left eye

Correct Answer: A,B,C,D

Rationale: In addition to ophthalmic medications (eg, beta blockers, cholinergic medications) and oral or IV carbonic anhydrase inhibitors, clients with
acute angle-closure glaucoma (ACG) require the following measures to prevent further vision loss and ensure safety:
• Administration of an osmotic diuretic (eg, mannitol) to reduce intraocular pressure (IOP). Mannitol increases plasma oncotic
pressure, pulling water from the extravascular space into the intravascular space. This fluid, along with the diuretic, is excreted through
the kidneys, thereby reducing IOP. This is similar to the management of cerebral (brain) edema (Option 1).
• Administration of an antiemetic medication (eg, ondansetron) to alleviate nausea because vomiting can cause a sharp increase in IOP,
further worsening acute ACG (Option 2)
• Implementation of fall precautions (eg, provide nonskid socks, turn on bed alarm, clear a pathway to the bathroom) to ensure client
safety. Many eye drops cause blurred vision for several minutes after administration, worsening the client's already impaired vision
(Option 3).
• Instruction to avoid activities that increase IOP (eg, bending/stooping, straining, coughing, blowing the nose, laughing) (Option 4)
(Option 5) Applying a pressure patch to the eye is typically done as a postoperative intervention for ocular surgeries (eg, corneal
transolantation) and is not necessary to include in the olan of care for this client.