Nokea
The nurse is caring for a 12-year-old client.
History and Physical Vital Signs Body System Findings
General- The client has a 2-day history of decreased appetite, nausea, fatigue, and headaches, the client had a "sore throat" 2 weeks ago that resolved without treatment; BMl is in the 65th percentile
Eye, Ears, Nose, and Throat (EENT)- Periorbital edema; no changes in vision
Pulmonary- Lung sounds clear bilaterally; no increased work of breathing; no cough Cardiovascular- S1 and S2 heard on auscultation; no murmur auscultated; 3+ bilateral lower extremity edema is noted
Gastrointestinal- Bowel sounds present, no masses or tenderness felt Musculoskeletal No joint pain or swelling
Genitourinary- Decreased urination; dark, cola-colored urine
Which of the following statements by the parent indicate a correct understanding of the teaching? Select all that apply.
- A. I will contact the health care provider immediately if my child experiences any vision changes, such as blurriness.'
- B. I will schedule a follow-up visit for a urinalysis and blood pressure check.'
- C. My child may notice small amounts of blood in the urine for several weeks.'
- D. My child should avoid exposure to friends and family who show signs of an upper respiratory infection.'
- E. My child will require lifelong blood pressure medication with frequent monitoring at home.'
Correct Answer: A,B,C,D
Rationale: Monitoring vision , follow-up tests , expecting hematuria , and avoiding infections are correct. Lifelong medication is not typical.
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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 client statement would indicate that the client requires additional therapy to appropriately cope with the panic disorder?
- A. I have realized that even though my panic attacks are under control, I will eventually need to be tapered off the alprazolam.'
- B. I purchased a watch that alerts me when my heart or respiratory rate increases so I can begin breathing exercises to calm myself.'
- C. My support group has been helping me to identify when my thoughts are not realistic so I can talk myself out of feelings of panic.'
- D. Taking the bus to work has been a trigger for me so my boss is letting me work from home.'
Correct Answer: D
Rationale: Avoiding triggers like the bus without coping strategies indicates reliance on avoidance, requiring further therapy.
The nurse is caring for a 12-year-old client.
History and Physical Vital Signs Body System Findings
General- The client has a 2-day history of decreased appetite, nausea, fatigue, and headaches, the client had a "sore throat" 2 weeks ago that resolved without treatment; BMl is in the 65th percentile
Eye, Ears, Nose, and Throat (EENT)- Periorbital edema; no changes in vision
Pulmonary- Lung sounds clear bilaterally; no increased work of breathing; no cough Cardiovascular- S1 and S2 heard on auscultation; no murmur auscultated; 3+ bilateral lower extremity edema is noted
Gastrointestinal- Bowel sounds present, no masses or tenderness felt Musculoskeletal No joint pain or swelling
Genitourinary- Decreased urination; dark, cola-colored urine
The client is diagnosed with acute postinfectious glomerulonephritis. The client is most at risk for. and
- A. Pyelonephritis
- B. Cerebral edema
- C. Pulmonary edema
- D. Hemorrhagic cystitis
Correct Answer: B,C
Rationale: Glomerulonephritis increases risks for cerebral and pulmonary edema due to fluid overload.
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 an 88-year-old client with pneumonia.
Nurses' Notes Vital Signs Medical-Surgical Unit
0800: The client has dyspnea that worsens on exertion, a productive cough, and fever. Crackles are heard in the bilateral lower lung lobes.
1000: The client is restless, coughs frequently, and struggles to breathe.
The nurse should first Select... to Select... ...
- A. Elevate the head of the bed
- B. Administer albuterol nebulizer
- C. Assist the client to drink clear fluids
- D. Thin secretions
- E. Increase lung expansion
- F. Relax bronchial smooth muscles
Correct Answer: A,E
Rationale: Elevating the head of the bed promotes lung expansion to improve breathing in pneumonia.
The nurse is caring for a 75-year-old female client. Nurses' Notes Laboratory Results Diagnostic Results Emergency Department
The client is transferred to the emergency department from a skilled nursing facility for a 3-day history of left lower quadrant abdominal pain rated 8 on a scale of 0-10, loss of appetite, and nausea. Although the client has a history of chronic constipation, she has had 2 or 3 loose stools daily for 1 week. The client reports tenderness on deep palpation of the left lower quadrant. There is an area of blanchable redness on the coccyx. The stool is positive for occult blood.
The client has residual left-sided weakness from an ischemic stroke 2 years ago and ambulates with a walker. The client reports falling several times in the past 6 months; the last fall was 3 weeks ago No ecchymosis or injuries are noted. The client had a hysterectomy and salpingo-oophorectomy for uterine fibroids 20 years ago. Vital signs are T 100 F (37.8 C), P 98, RR 17, BP 126/68, and SpOz 97% on room air.
Medical-Surgical Unit: 4 Days Later
The client continues to experience left lower quadrant pain, decreased appetite, and nausea. Today, she developed chills. Stool frequency has not increased. Severe tenderness is noted in the left lower quadrant, and a mass is palpable. Vital signs are T 101.3 F (38.5 C), P 112, RR 17, BP 110/80, SpO, 97% on room air.
Complications associated with acute diverticulitis include ........, ........ and ........
- A. Pyelonephritis
- B. Fistula formation
- C. Bowel perforation
- D. Abscess formation
- E. Rupture of the appendix
Correct Answer: B,C,D
Rationale: Diverticulitis complications include fistula , perforation , and abscess .