A nurse is caring for an older adult client.

Exhibits

Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again

System	Findings
General	Adult child accompanying parent reports decline in client, expressing concern over memory and thought process, appetite, and self-care. Adult child states, "My sibling and I hired help at home for my parent. We thought that would help but it has not.. I found the title to the car today, signed over to me.
Physical	Client makes poor eye contact, speaks in a monotone voice, and has a lack of facial expression. Client reports sleeping 7 hr a night and getting up "once or twice per night to go to the bathroom. Client reports not wanting to eat anymore. Client reports not wanting to eat anymore. Client's child reports their parent has lost about 8 lb in the past month. Heart rate 68/min
Affect	Client says, "Why don't you just leave me? I am of no use."

The nurse is continuing to care for the client.

The nurse is reviewing the assessment findings.

For each assessment finding, click to specify if the finding is consistent with preeclampsia or HELLP syndrome. Each finding may support more than one disease process.

A nurse is assessing a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate 4 hr ago. The nurse notes pink-tinged urine in the drainage bag. Which of the following actions should the nurse take?

A nurse working in the emergency department (ED) is admitting a client.

Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again.

Nurses' Notes

Day 1, 1030:

Client reports feeling short of breath, productive cough with yellow sputum, and pleuritic chest pain. Runny nose, myalgia along with headache for the past 3 days. "I woke up feeling worse and started to feel nauseated and couldn't eat my breakfast, so I thought I should come in." Client reports pleuritic chest pain as 6 on a scale of 0 to 10. Skin is moist. Lungs sounds are diminished in lower lobes with crackles. Bowel sounds are normoactive in all quadrants. Last bowel movement this morning. Reports no difficulty urinating. Reports nausea with no vomiting. Able to move all extremities. Pedal pulses present +2. Client is oriented to person, place, and time.

A nurse is teaching about preventative measures to a female client who has chronic urinary tract infections. Which of the following instructions should the nurse include in the teaching?

A nurse is caring for a client who has respiratory depression from an opioid administration. After administering naloxone to the client, which of the following findings should the nurse expect?

The nurse is continuing to care for the client.

Complete the following sentence by using the list of options.

The provider has admitted the client to the inpatient obstetrics unit and written prescriptions based on the client's condition.

The action the nurse should take first is

A nurse is assessing a client who has type 1 diabetes mellitus and was. Which of the following clients should the nurse instruct the staff to indicates that the client might be experiencing hypoglycemia?

A nurse is providing care for a client who has esophageal cancer and has received radiation therapy. Which of the following findings should the nurse identify as the priority?

An occupational health nurse is providing teaching to a group of factory workers about proper lifting techniques. Which of the following statements should the nurse make?

A nurse is assessing a client following an esophagogastroduodenoscopy. Which of the following findings should the nurse report to the provider?