Exhibits

The nurse is reviewing the physician orders. Which of the following physician’s orders requires priority attention from the nurse? Select all that apply.

Select two conditions and two client finding to fill in each blank in the sentence. Separate using a comma.

The client has

The nurse is reviewing the physician orders. Which of the following physician’s orders requires priority attention from the nurse? Select all that apply.

Patient Data

Drag from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s progress.

A 70-year-old female presents to the emergency department through triage with a noticeable facial droop and garbled speech. After having a few drinks at a local seafood restaurant, the client's husband noticed his wife's speech became difficult to understand.

Flow sheets

1915

Arrival at emergency department

1920

Vital Signs:

- Temperature: 98.2° F (36.8° C)

- Heart rate: 92 beats/minute

- Respirations: 24 breaths/minute

- Blood pressure: 210/98 mmHg

- Oxygen saturation: 95% on room air

Imaging studies

1935

Head CT scan results:

- No evidence of intracranial hemorrhage

- No evidence of acute disease

Orders

- Obtain CT scan of the head.

- Insert a large bore peripheral IV.

- Start normal saline infusion at 50 mL/hour.

The client continues to have stable neurologic assessments. The nurse provides interventions to promote client safety while in the hospital. Of the interventions below, explain if it promotes clients safety or not, or does both.

A client with acquired immune deficiency syndrome (AIDS) and Pneumocystis jiroveci pneumonia has a CD4+ T cell count of 200 cells/mm³ (20%). The client asks the nurse why they have these recurring massive infections. Which pathophysiologic mechanism should the nurse describe in response to this client's question?

Reference Range:
T-helper CD4 cells [600 to 1500 cells/mm³ (60 to 75%)]

Specify which potential condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s response.

A client presents with the onset of a severe headache, fever, nuchal rigidity, and a petechial rash on arms and legs. The nurse recognizes the client is exhibiting symptoms of which condition?

The triage nurse does a rapid assessment of the client. Which data indicates the client is in need of immediate health interventions?

A 70-year-old female presents to the emergency department through triage with a noticeable facial droop and garbled speech. After having a few drinks at a local seafood restaurant, the client's husband noticed his wife's speech became difficult to understand.

Flow sheets

1915

Arrival at emergency department

1920

Vital Signs:

- Temperature: 98.2° F (36.8° C)

- Heart rate: 92 beats/minute

- Respirations: 24 breaths/minute

- Blood pressure: 210/98 mmHg

- Oxygen saturation: 95% on room air

Imaging studies

1935

Head CT scan results:

- No evidence of intracranial hemorrhage

- No evidence of acute disease

Orders

- Obtain CT scan of the head.

- Insert a large bore peripheral IV.

- Start normal saline infusion at 50 mL/hour.

• The nurse administered tPA and conducted neurologic assessments every 15 minutes during the infusion.
• The tPA infusion finished and the nurse performed neurologic assessments every 30 minutes for the 6 hours following the administration.
• The client was noted to be stable with unchanged neurologic assessments.
• The nurse begins to plan care for the client's recovery and identifies interdisciplinary team members who can assist with the client's recovery.

Select the interdisciplinary team members who should assist the client in recovery.