Nokea
A nurse in an outpatient clinic is caring for a client.
Assessment
0840:
Client is calm and cooperative. Skin warm and dry. No rash noted. Lung sounds clear. Abdomen
soft to palpation with fundal height at 20 cm. Fetal heart rate 150/min. Bowel sounds active in all
four quadrants. No edema to lower extremities. Client denies visual changes or severe headaches.
Weight gain of 1.8 kg (4 lb) since last visit. Small amount of mucoid discharge noted on perineal
pad
Laboratory Results
0900:
Urine dipstick:
pH 6.0 mg/d (4.6 to 8 mg/dL)
Specific Gravity 1.022 (1.010 to 1.025)
Leukocyte esterase negative (Negative)
Nitrite negative (Negative)
Protein trace negative (Negative)
Glucose negative (Negative)
Ketones none (None)
Bilirubin none (None)
Blood none (None)
Nurses' Notes
0830:
Client reports to clinic for monthly prenatal visit. Client is at 20 weeks of gestation. Since last
visit, client reports concerns about the occurrence of intermittent mild backaches, increased
heartburn, generalized itching, and vaginal discharge.
Vital Signs
0830:
BP 124/68 mm Hg
Heart rate 80/min
Temperature 37° C (98.6° F)
Respiratory rate 16/min
Weight 67.1 kg (148 lb)
Which of the following statements should the nurse include in the client's teaching?
- A. Take hot showers to help relieve itching
- B. Wear flat or low-heeled shoes
- C. You can douche twice weekly
- D. Wear loose-fitting clothing
- E. Try using an abdominal support belt
- F. You should avoid fried foods
- G. Eat two large meals a day
Correct Answer: B,D,F
Rationale: Wearing flat shoes, wearing loose-fitting clothes, and avoiding fried foods are beneficial practices during pregnancy.
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A nurse is caring for a client who has severe hypertension and is to receive nitroprusside via continuous IV infusion.
Which of the following actions should the nurse plan to take?
- A. Keep calcium gluconate at the client's bedside
- B. Monitor blood pressure every 2 hr.
- C. Protect IV bag from exposure to light.
- D. Attach an inline filter to the IV tubing.
Correct Answer: C
Rationale: The correct answer is C: Protect IV bag from exposure to light. This is important because certain medications in IV bags can degrade when exposed to light, leading to reduced efficacy or potential harm to the patient. Keeping the IV bag protected helps maintain the integrity of the medication.
Choice A is incorrect because calcium gluconate should be stored properly but doesn't necessarily need to be kept at the bedside at all times.
Choice B is incorrect as monitoring blood pressure every 2 hours may not be necessary for all patients and is not specific to the scenario given.
Choice D is incorrect as attaching an inline filter to the IV tubing may be necessary in certain situations but is not the most relevant action based on the information provided.
A nurse is caring for an infant who has coarctation of the aorta.
Which finding should the nurse identify as expected?
- A. Weak femoral pulses
- B. Bounding pulses in the lower extremities
- C. Cyanosis of the hands and feet
- D. Frequent episodes of bradycardia
Correct Answer: A
Rationale: The correct answer is A: Weak femoral pulses. In pediatric patients, weak femoral pulses are expected due to the normal physiological differences in vascular resistance between upper and lower extremities. This is known as the "femoral pulse lag." Bounding pulses in the lower extremities (choice B) would be abnormal and could indicate a vascular disorder. Cyanosis of the hands and feet (choice C) suggests poor perfusion and oxygenation, which is concerning. Frequent episodes of bradycardia (choice D) could indicate cardiac issues and are not expected in a healthy pediatric patient.
A nurse is caring for a client who is alert and oriented and is receiving continuous ECG monitoring. The cardiac rhythm strips shows a wavy baseline, no distinguishable P waves, and an increased heart rate.
The nurse should identify the cardiac rhythm as which of the following?
- A. Ventricular asystole
- B. Second-degree heart block
- C. Sinus Tachycard
- D. Atrial fibrillation
Correct Answer: D
Rationale: The correct answer is D: Atrial fibrillation. In atrial fibrillation, the atria quiver instead of contracting effectively, leading to an irregular and rapid heart rate. This can be identified on an ECG by the absence of distinct P waves and irregular R-R intervals. Ventricular asystole (A) is the absence of ventricular contractions, second-degree heart block (B) is characterized by intermittent conduction block between the atria and ventricles, and sinus tachycardia (C) is a regular rapid heart rate originating from the sinus node.
A nurse is assessing a client who has bipolar disorder and is experiencing a depressive episode.
Which finding should the nurse expect?
- A. Move quickly from one idea to the next
- B. Feelings of hopelessness or worthlessness
- C. Decreased energy and fatigue
- D. Difficulty concentrating or making decisions
- E. Changes in appetite, either increased or decreased
Correct Answer: B
Rationale: The correct answer is B: Feelings of hopelessness or worthlessness. This is a key symptom of depression and is often present in individuals experiencing a depressive episode. It is important for the nurse to recognize this as it can indicate a serious mental health issue that requires intervention. Choices A, C, D, and E are also common symptoms of depression, but they are not as specific to the core of the condition as feelings of hopelessness or worthlessness. Moving quickly from one idea to the next (A) may suggest mania or hypomania rather than depression. Decreased energy and fatigue (C), difficulty concentrating or making decisions (D), and changes in appetite (E) are also common in depression, but they are not as indicative of the deep emotional distress associated with feelings of hopelessness or worthlessness.
A nurse is caring for a client
History and Physical
Day 1,0900:
A 52-year-old client brought to emergency department by adult child. Client is alert and oriented
to person and time but does not know where they are. No history of substance use according to
client's adult child. Client exhibits constant movements and poor concentration. Hair and
clothing are unclean, appears to be listening to unseen others. Skin turgor poor.
Nurses Notes
Day 1. 0915
The client's adult child reports the client has not slept for 2 days and has become obsessed with
cleaning the house and hosting parties. At times the client is overly joyous and has a very
elevated sense of self-confidence. The adult child states that the client has also demonstrated
very impulsive spending habits and expresses concern about the client giving away large sums
of money to others
The client's speech is very pressured, disorganized, and loud. Client unable to recall the last time
they ate
Vital Signs
Day 1, 0905:
Temperature 37.1° C (98,8° F)
Heart rate 120/min
Respiratory rate 19/min
BP 138/88 mm Hg
Oxygen saturation 98% on room air
Select the 4 findings that require immediate follow up
- A. Hallucinations
- B. Heart rate
- C. Sleep patterns
- D. Skin turgor
- E. Hygiene
Correct Answer: A,B,C,D
Rationale: The correct answer is A, B, C, and D. Hallucinations (A) may indicate a serious health issue needing immediate attention. Abnormal heart rate (B) could signify a cardiac problem. Disrupted sleep patterns (C) may indicate underlying health conditions. Reduced skin turgor (D) can signal dehydration or malnutrition. Choices E, F, and G are not typically indicative of immediate follow-up needs in this context.