A nurse is caring for a client in the outpatient mental health clinic
History and Physical
2 months ago:
Client states, "My depression has been getting a little worse Lately."
Client reports increased fatigue, sadness, and hypersomnia over the last few months. Client reports their manifestations have
been well-controlled "for years" on fluoxetine, but "it seems to
have stopped working." Client denies any physical complications or suicidal ideation.
Client has history of depression and hyperlipidemia.
Client lives at home with partner and 4-year-old child. Denies alcohol, illicit drug, or tobacco use Exercises occasionally.

Click to highlight the findings that indicate the client is experiencing adverse effects of the medication. To deselect a finding, click on the finding again
Nurses' Notes
Today

Client states "I’m feeling much better." They report less fatigue even though they have difficulty sleeping. Client reports they are not sad anymore but are experiencing more frequent headaches. Client continues to deny any suicidal ideation

Vital Signs
Today
BP 149/91 mm Hg

Heart rate 75min

Respiratory rate 18/min

A nurse is caring for a client who has given informed consent for electroconvulsive therapy. Just before the procedure, the client tells the nurse she is considering not going forward with the treatment. Which of the following statements by the nurse is appropriate?

A nurse is caring for a client who is postoperative following a right hip arthroplasty.

Vital Signs

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1330:

Temperature 36.8° C (98.2° F) Heart rate 88/min

Respiratory rate 16/min BP 110/64 mm Hg

Oxygen saturation 96% on oxygen 3 U/min via simple face mask 1345:

Temperature 37° C (98.6" F) Heart rate 112/min Respiratory rate 20/min

BP 108/60 mm Hg

Oxygen saturation 94% on oxygen 3 L/min via simple face mask 1400

Temperature 38.3° C (101° F) Heart rate 152/min Respiratory rate 26/min

BP 90/54 mm Hg

Oxygen saturation 89% on oxygen 4 Umin a simple face mask

For each assessment finding, specify if the finding is consistent with malignant hyperthermia, latex allergy, or hypovolemic shock. Each finding may support more than 1 disease process

The nurse continues to care for the client.

Nurses' Notes Day 1, 0900:
Client reports lower back pain and pinkish vaginal discharge. Uterine contractions every 8 minutes, palpate strong, duration 30 seconds.
FHR baseline 145, minimal variability.

Cervical exam indicates 2 cm, 50% effaced, 0 station. Membranes intact.
CBC and urinalysis collected and sent to lab. Assessment
Nurses' Notes Findings
Client rates lower back pain a 0 on a scale from 0 to 10. No reports of vaginal discharge. Membranes intact
No uterine contractions noted.

FHR baseline 138, minimal variability.

No further reports of burning with urination. Laboratory Results
WBC 12.000/mm3 (5.000 to 10.000/mm3

Platelet count 188,000/mm2 (150,000 to 400,000/mm Vital Signs
Day 1,0900:

Admission:

Temperature 38.4° C (101.1° F) Heart rate 85/min
Respiratory rate 16/min

Blood pressure 120/78 mm Hg

Pre-pregnancy BMI 27.6

Current BMI 29.9

Day 2, 0800:

Temperature 37.1° C (98.7° F) Heart rate 85/min
Respiratory rate 16/min

Blood pressure 120/78 mm Hg
Assessment Day 1,0900:
Nurses' Notes

30-year-old client at 33 weeks gestation, Gravida 4 Para 3 Maternal blood type: Rh+ Last pregnancy resulted in a preterm spontaneous vaginal birth at 30 weeks gestation.

highlight the findings that indicate improvement in the client's condition. To deselect a finding

A nurse is providing teaching to a client who has a new prescription for enoxaparin. Which of the following medications for pain relief should the nurse include in the teaching that can be taken concurrently with enoxaparin?

A nurse is teaching a prenatal class about infection prevention at a community center.
Which of the following statements by a client indicates an understanding of the teaching?

A nurse is preparing to administer levothyroxine 50 micrograms to a client. Available is levothyroxine 0.025 mg/tablet. How many tablets should the nurse administer per dose? (Round to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is caring for a client who has end-stage liver disease and is undergoing a paracentesis. Which of the following actions should the nurse take to evaluate the effectiveness of the procedure?

A nurse is caring for a client who is 12 hr postpartum and has a third-degree perineal laceration. The client reports not having a bowel movement for 4 days. Which of the following medications should the nurse administer?

A nurse has identified tasks to delegate to a group of assistive personnel (AP) after receiving change-of-shift report. Identify the sequence of steps the nurse should follow when delegating tasks to the APs. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)