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A nurse is caring for a client in the emergency The nurse should plan to administer an opioid analgesic, such as morphine, for
department (ED). acute pain. Since the client is experiencing nausea and vomiting, the nurse should
Physical Examination also ensure they are NPO. The client is likely experiencing cholecystitis, which
Client presents to the ED with upper abdominal pain that typically presents with nausea, vomiting, upper abdominal pain that radiates to the
radiates to the right shoulder. Client rates pain as 7 on a right shoulder, fever, and dyspepsia. The client also has elevated liver enzymes
scale of 0 to 10. Client also reports nausea, vomiting, and and a WBC count, which is consistent with cholecystitis. Surgical management for
dyspepsia. cholecystitis might be indicated. The nurse should monitor the client's stool and
Client is awake, alert, and oriented x3. Lung sounds clear urine color because a biliary obstruction from gallstones may cause clay-colored
bilaterally, S1 and S2 heart tones noted. All pulses stools and dark urine.
palpable. Bowel sounds active in all 4 quadrants.
Complete the diagram by dragging from the choices
below to specify what condition the client is most likely
experiencing, 2 actions the nurse should take to address
that condition, and 2 parameters the nurse should
monitor to assess the client's progress.
, A nurse is caring for a client who was just admitted from Fluid volume overload is incorrect. While the client is experiencing an increased
the emergency department (ED). respiratory rate and shortness of breath, fluid volume overload typically includes
Nurses' Notes moist crackles on auscultation, pitting edema in dependent areas, neck vein
0945: distension, and hypertension.
Client is experiencing a sickle cell crisis. Client states that Right-sided heart failure is incorrect. While clients who have sickle-cell disease
they began experiencing pain in the lower extremities 3 are at risk for developing heart failure, the client does not have manifestations of
days ago and is now experiencing pain in the chest, right-sided heart failure. Right-sided heart failure typically presents with signs of
rating it as 4 on scale of 0 to 10. fluid volume overload, which includes jugular vein distention, dependent edema,
Oxygen at 3 L/min via nasal cannula in place. and blood pressure alterations.
Oral mucosa pink, no cyanosis. Acute chest syndrome is correct. The client is most likely experiencing acute chest
Pulses palpable in all four extremities, no peripheral syndrome, which can be caused by respiratory infections and debris from sickled
edema noted. cells. The client is displaying manifestations of acute chest syndrome, which
Respirations even and slightly labored; lung sounds with include cough, shortness of breath, wheezing, tachypnea, fever, and chest pain.
slight wheezing in left upper lobe. Pneumonia is correct. The client is most likely experiencing pneumonia as
Abdomen soft and nontender, bowel sounds active in all evidenced by the manifestations of cough, shortness of breath, fever, tachypnea,
four quadrants. blood-tinged sputum, and chest pain.
0.45% sodium chloride IV at 200 mL/hr infusing to left Pneumothorax is incorrect. While the client is experiencing increased respiratory
hand with no reports of pain or swelling at the site. distress, a pneumothorax typically presents with reduced or absent breath sounds
Drag words from the choices below to fill in each blank in and unequal chest expansion.
the following sentence.
A nurse is caring for a client. Temperature is consistent with pneumonia. Fever is a manifestation of pneumonia
Nurses' Notes and is related to inflammation or infection.
1200: Breath sounds are consistent with emphysema, asthma, and pneumonia. The
Client was admitted to the unit with shortness of breath, a client's wheezing is a manifestation of emphysema, asthma, and pneumonia. It is
nonproductive cough, chest discomfort, and myalgia. the result of narrowed airways and alveoli.
Prefers orthopneic position. Client reports that ABG results are consistent with emphysema and pneumonia. The client's ABG
manifestations began about 2 days ago. results indicate respiratory acidosis, which is a manifestation of emphysema and
For each assessment finding, click to specify if the finding pneumonia.
is consistent with emphysema, asthma, or pneumonia. Respiratory rate is consistent with emphysema, asthma, and pneumonia. The
Each finding may support more than 1 disease process. client's respiratory rate is a manifestation of emphysema, asthma, and pneumonia.
Heart rate is consistent with emphysema and pneumonia. The client is
experiencing tachycardia, which is a manifestation of emphysema and pneumonia.
Cough is consistent with emphysema, asthma, and pneumonia. The client's cough
is a manifestation of emphysema, asthma, and pneumonia.
A nurse is providing teaching to a client who has a severe My joints ache because I have Lyme disease."
form of stage II Lyme disease. Which of the following
statements made by the client reflects and understanding Lyme disease is a vector-borne illness transmitted by the deer tick. The disease
of the teaching? course occurs in three stages beginning with joint and muscle pain in stage I. If
left untreated, these symptoms continue throughout stage II and, by stage III,
become chronic. Other chronic complications include memory problems and
fatigue.