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

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.
1000:
The client reports difficulty raising the arms and inability to squeeze the
fingers. The client reports chest tightness and difficulty breathing.
1030:
The client is breathless while speaking. Respirations are shallow and
labored. The client is diaphoretic. The skin is pale and cool. No
audible wheezing or stridor is present.

Which of the following statements by the client's spouse indicate that the teaching has been effective? Select all that apply.

A. My children and I need to get tested because we could become paralyzed, too.'
B. My spouse may have neurologic deficits for several months.'
C. My spouse may need a temporary feeding tube for nutrition while on the ventilator.'
D. Our children should refrain from getting a yearly flu vaccine.'
E. This was most likely triggered by the recent flu-like illness.'

Correct Answer: B,C,E

Rationale: Prolonged deficits , feeding tube need , and viral trigger are accurate. GBS is not contagious , and flu vaccines are recommended.

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.

Click to highlight below the 3 findings that should concern the nurse.

A. The client was diagnosed with gestational diabetes mellitus and prescribed insulin, but she reports not taking the insulin.
B. The client reports cigarette smoking (3-5 cigarettes/day) but denies alcohol or recreational drug use.
C. The client received treatment for bacterial vaginosis during the second trimester.
D. The client has gained 55 lb (25 kg) during the pregnancy. Group B Streptococcus result is negative.

Correct Answer: A,B,D

Rationale: Non-compliance with insulin , smoking , and excessive weight gain increase neonatal risks.

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.
1000:
The client reports difficulty raising the arms and inability to squeeze the
fingers. The client reports chest tightness and difficulty breathing.

For each intervention, click to specify if the intervention is appropriate or inappropriate for the care of the client.

A. Ensure bedside suction is set up
B. Place a bag valve mask at the bedside
C. Ensure intubation equipment is available
D. Reposition the client in the bed every 2 hours
E. Place the client on continuous cardiac monitoring
F. Apply a sequential compression device to the legs
G. Mark the appropriate surgical site for a tracheotomy

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

Rationale: Suction , bag valve mask , intubation equipment , repositioning , cardiac monitoring , and compression devices prepare for GBS complications. Tracheotomy marking is premature.

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

For each potential intervention, click to specify if the Intervention is indicated or not indicated for the care of the client.

A. Initiate seizure precautions
B. Encourage frequent ambulation
C. Start a magnesium sulfate infusion
D. Prepare to administer antihypertensives

Correct Answer: A,C,D

Rationale: Seizure precautions , magnesium sulfate , and antihypertensives are indicated for preeclampsia with severe features. Ambulation is not prioritized due to risk of falls.

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 contacting a client at 28 weeks gestation to review laboratory results and schedule a follow-up prenatal visit. Laboratory Results Laboratory Test and Reference Range 12 Weeks Gestation 26 Weeks Gestation 28 Weeks Gestation
WBC (prostent) 5,000-1多份 (5.0-15.0 × 10°/L) 8,900/mm3 (8.9 × 10°/L) 16,500 /mm° (16.5 × 10%/L)
Hemoglobin (pregnant) 11-16 g/dL (110-160 g/L) 13 g/dL (130 g/L) 10.8 g/dL (108 g/L) Hematocrit (pregnant) 33%-47% (0.33-0.47) 39% (0.39) 32% (0.32)
Chlamydia Negative Positive Negative Hemoglobin A1c 4.0%-5.9% 5.1%
1-hour oral glucose challenge test <140 mg/dL (7.8 mmol/L) 175 mg/dL (9.7 mmol/L)
3-hour oral glucose tolerance test Fasting: <110 mg/dL (6.1 mmol/L) 1 hour: <180 mg/dL (10.0 mmol/L) 2 hour: <140 mg/dL (7.8 mmol/L 3 hour: <70-115 mg/dL (<6.4 mmol/L) Fasting: 115 mg/dL (6.4 mmol/L) 1 hour: 205 mg/dL (11.4 mmol/L) 2 hour: 162 mg/dL (9.0 mg/dL) 3 hour: 135 mg/dL (7.5 mg/dL)

The nurse should be most concerned about the client's. and anticipate the client's need for

A. Glucosuria
B. Contractions
C. Blood pressure
D. Blood glucose levels
E. Insulin
F. A urine culture
G. Antihypertensives

Correct Answer: D,E

Rationale: Blood glucose levels are critical in gestational diabetes, requiring insulin to manage hyperglycemia.