NGN
Study online at https://quizlet.com/_eu1u44
1. Q:158 A nurse assisting with the care of a client who presents to the labor and
delivery unit.
Nurses note: 1700: client reports sudden onset of severe abdominal pain and
vaginal bleeding/ moderate amount of dark red blood noted on the perineal
pad. Abdominal rigid and tender to touch. Fetal HR: 125/min. 1715: contraction
frequency 1.5-2 min Duration 60-90 sec, strong to palpation. etc......
Nurse assisting with clients care should expect which of the following prescrip-
tions from the clients provider? (SATA): Monitor vital signs at least every 15 mins
obtain type and crossmatch
measure blood loss by weighing pads
insert a large-bore IV catheter
2. Q159: A nurse is assisting with the care of a client.
Nurse notes:
0900: client reports a 3 month history of a intermittent diarrhea and abdominal
pain. reports unintentional weight loss of 5.5kg (12lbs) in 3 months
0930: stool sample obtained fecal occult blood test ( fatty and appearance and
foul odor noted)
For each finding, click and specify if the finding is consistent with: ulcerative col-
itis, diverticulitis, or Crohns disease?: Ulcerative colitis: Abdomen cramping, weight loss, diarrhea,
anemia
Diverticulitis: abdomen cramping
Crohn's disease: Abdomen cramping, weight loss, diarrhea, anemia
3. Q 160: Report an issue, a nurse is assisting with the care of a client:
H&P: 6 weeks ago: client presents to an outpatient psych office for evaluation of
depression. symptoms started 2 months ago. Client reports depressed mood,
lack of pleasure in activities that they enjoyed, hypersomnia, and fatigue. The
nurse is reinforcing teaching for the client and their family about potential
adverse effects of the clients prescribe medications.
For each potential adverse effect, click to specify if the effect is consistent with
agranulocytosis, neuroleptic malignant syndrome, or serotonin syndrome: -
Agranulocytosis: sore throat, high fever
, NGN
Study online at https://quizlet.com/_eu1u44
Neuroleptic malignant syndrome: BP changes, high fever
Serotonin syndrome: Disorientation, BP changes, tachycardia, high fever
4. Q161: Report an issue: The nurse is assisting in the care of the client who is
in the behavioral health unit.
Nurses notes: 2015: 2030: client appears dishevels with matted hair and stained
clothing. Client states I have to get out of here, i hear helicopters. They are
coming to get me, My name is Jamie and you are the devil." Client appears to
be responding to internal stimuli but is less outwardly agitated
Put the words from the choices below to fill in each blank in the following
The nurse should plan to _______ and ___________: Ask the client what they are hearing
Reduce excess stimulation around the client
5. The nurse assisting in the care of the client who is on the behavioral health
unit.
Nurses notes: 2015: 2030: client appears dishevels with matted hair and stained
clothing. Client states I have to get out of here, i hear helicopters. They are
coming to get me, My name is Jamie and you are the devil." Client appears to
be responding to internal stimuli but is less outwardly agitated
The client is exhibiting _____ as evidences by _______: visual hallucinations
verbal statements
6. Q162: The nurse continues to assist in the care of the client
Day 5 0700: Ziprasidone 20 mg IM left deltoid muscle. Paliperidone 6mg PO
Nurses notes: 2030: client appears with matted hair and staining of clothing
attempting to get out of handcuffs. The client states I have to get out of here i
hear helicopters, they are coming to get me. My name is Jamie and you are the
devil......(same as question 161 )
Nurse collecting data from client 5 days after admission
For each finding: click to specify whether the finding indicated the clients
condition has improved or declined: Response to other clients
Sleep pattern
Hygiene patterns
7. Q 163: A nurse is assisting with the care of a client who is pregnant
Nurse note: 0900 Client is at 31 gestation and presents with severe headache
, NGN
Study online at https://quizlet.com/_eu1u44
unrelieved by acetaminophen. Reports urinary frequency and decreased fetal
movement, client is gravida 3, para 2 with one preterm birth
Select 4 findings that the nurse should identify as a potential prenatal condi-
tion: Blood presssure
Fetal activity
Headache
Urine protein
8. Q164:
Nurse note: 0900 Client is at 31 gestation and presents with severe headache
unrelieved by acetaminophen. Reports urinary frequency and decreased fetal
movement, client is gravida 3, para 2 with one preterm birth
Report constant and throbbing headache and rate pain 6 on a scale of 10.
Denies visual disturbances, +3 pitting edema lower extremities...........
For each finding click to specify if the finding is consistent with preeclampsia
or HELLP syndrome: Pre eclampsia: Blood pressure, platelet count
HELLP syndrome: hemoglobin, platelet count, alanine aminotransferase
9. Q165: A nurse is assisting with the care of a client who has pneumonia
Admission assessment: 0100 Pedal pulse 2+ clients skin warm to touch. crackles
auscultated in lower lung lobes bilaterally, mucous membranes show color
expected for clients skin tone and dry, client reports productive cough with
yellow sputum. allergy to PCN
For each potential nursing action, click to specify if the potential action is
anticipated or contraindicated for the client: Elevate extremity: Anticipated
Send the catheter tip for culture: Contraindicated
Assist in inserting a new IV catheter in a site distal to infiltration site: contraindicated
Suggest irrigating the IV catheter: Contraindicated
Apply a cool compress to the extremity: Anticipate
Administer phytonadione: Contraindicated
10. Q 166; A nurse is assisting with the care of a client who is in active labor
1130: client admitted to labor and delivery. gravida 1 para 0 at 40 weeks of
gestation. client presents with contractions every 5 to 6 min 30 to 40 seconds
duration, 2+ intensity, client reports their water broke and the fluid was clear.
Study online at https://quizlet.com/_eu1u44
1. Q:158 A nurse assisting with the care of a client who presents to the labor and
delivery unit.
Nurses note: 1700: client reports sudden onset of severe abdominal pain and
vaginal bleeding/ moderate amount of dark red blood noted on the perineal
pad. Abdominal rigid and tender to touch. Fetal HR: 125/min. 1715: contraction
frequency 1.5-2 min Duration 60-90 sec, strong to palpation. etc......
Nurse assisting with clients care should expect which of the following prescrip-
tions from the clients provider? (SATA): Monitor vital signs at least every 15 mins
obtain type and crossmatch
measure blood loss by weighing pads
insert a large-bore IV catheter
2. Q159: A nurse is assisting with the care of a client.
Nurse notes:
0900: client reports a 3 month history of a intermittent diarrhea and abdominal
pain. reports unintentional weight loss of 5.5kg (12lbs) in 3 months
0930: stool sample obtained fecal occult blood test ( fatty and appearance and
foul odor noted)
For each finding, click and specify if the finding is consistent with: ulcerative col-
itis, diverticulitis, or Crohns disease?: Ulcerative colitis: Abdomen cramping, weight loss, diarrhea,
anemia
Diverticulitis: abdomen cramping
Crohn's disease: Abdomen cramping, weight loss, diarrhea, anemia
3. Q 160: Report an issue, a nurse is assisting with the care of a client:
H&P: 6 weeks ago: client presents to an outpatient psych office for evaluation of
depression. symptoms started 2 months ago. Client reports depressed mood,
lack of pleasure in activities that they enjoyed, hypersomnia, and fatigue. The
nurse is reinforcing teaching for the client and their family about potential
adverse effects of the clients prescribe medications.
For each potential adverse effect, click to specify if the effect is consistent with
agranulocytosis, neuroleptic malignant syndrome, or serotonin syndrome: -
Agranulocytosis: sore throat, high fever
, NGN
Study online at https://quizlet.com/_eu1u44
Neuroleptic malignant syndrome: BP changes, high fever
Serotonin syndrome: Disorientation, BP changes, tachycardia, high fever
4. Q161: Report an issue: The nurse is assisting in the care of the client who is
in the behavioral health unit.
Nurses notes: 2015: 2030: client appears dishevels with matted hair and stained
clothing. Client states I have to get out of here, i hear helicopters. They are
coming to get me, My name is Jamie and you are the devil." Client appears to
be responding to internal stimuli but is less outwardly agitated
Put the words from the choices below to fill in each blank in the following
The nurse should plan to _______ and ___________: Ask the client what they are hearing
Reduce excess stimulation around the client
5. The nurse assisting in the care of the client who is on the behavioral health
unit.
Nurses notes: 2015: 2030: client appears dishevels with matted hair and stained
clothing. Client states I have to get out of here, i hear helicopters. They are
coming to get me, My name is Jamie and you are the devil." Client appears to
be responding to internal stimuli but is less outwardly agitated
The client is exhibiting _____ as evidences by _______: visual hallucinations
verbal statements
6. Q162: The nurse continues to assist in the care of the client
Day 5 0700: Ziprasidone 20 mg IM left deltoid muscle. Paliperidone 6mg PO
Nurses notes: 2030: client appears with matted hair and staining of clothing
attempting to get out of handcuffs. The client states I have to get out of here i
hear helicopters, they are coming to get me. My name is Jamie and you are the
devil......(same as question 161 )
Nurse collecting data from client 5 days after admission
For each finding: click to specify whether the finding indicated the clients
condition has improved or declined: Response to other clients
Sleep pattern
Hygiene patterns
7. Q 163: A nurse is assisting with the care of a client who is pregnant
Nurse note: 0900 Client is at 31 gestation and presents with severe headache
, NGN
Study online at https://quizlet.com/_eu1u44
unrelieved by acetaminophen. Reports urinary frequency and decreased fetal
movement, client is gravida 3, para 2 with one preterm birth
Select 4 findings that the nurse should identify as a potential prenatal condi-
tion: Blood presssure
Fetal activity
Headache
Urine protein
8. Q164:
Nurse note: 0900 Client is at 31 gestation and presents with severe headache
unrelieved by acetaminophen. Reports urinary frequency and decreased fetal
movement, client is gravida 3, para 2 with one preterm birth
Report constant and throbbing headache and rate pain 6 on a scale of 10.
Denies visual disturbances, +3 pitting edema lower extremities...........
For each finding click to specify if the finding is consistent with preeclampsia
or HELLP syndrome: Pre eclampsia: Blood pressure, platelet count
HELLP syndrome: hemoglobin, platelet count, alanine aminotransferase
9. Q165: A nurse is assisting with the care of a client who has pneumonia
Admission assessment: 0100 Pedal pulse 2+ clients skin warm to touch. crackles
auscultated in lower lung lobes bilaterally, mucous membranes show color
expected for clients skin tone and dry, client reports productive cough with
yellow sputum. allergy to PCN
For each potential nursing action, click to specify if the potential action is
anticipated or contraindicated for the client: Elevate extremity: Anticipated
Send the catheter tip for culture: Contraindicated
Assist in inserting a new IV catheter in a site distal to infiltration site: contraindicated
Suggest irrigating the IV catheter: Contraindicated
Apply a cool compress to the extremity: Anticipate
Administer phytonadione: Contraindicated
10. Q 166; A nurse is assisting with the care of a client who is in active labor
1130: client admitted to labor and delivery. gravida 1 para 0 at 40 weeks of
gestation. client presents with contractions every 5 to 6 min 30 to 40 seconds
duration, 2+ intensity, client reports their water broke and the fluid was clear.
