Patient Data

Exhibits

Review of History, Physical, and Laboratory Results

Based on the findings, indicate whether each represents a modifiable risk factor, a non-modifiable risk factor, or is unrelated to type 2 diabetes mellitus.

Following a cardiac catheterization and placement of a stent in the right coronary artery, the nurse administers prasugrel to the client. To monitor for adverse effects from the medication, which assessment is most important for the nurse to include in this client's plan of care?

The parent of a child born with a myelomeningocele asks the nurse, "What did I do to deserve this?" Which response is most helpful?

Patient Data

The nurse reviews the assessment findings along with the physician orders. Which immediate interventions would the nurse initiate? Select all that apply.

Patient Data

Click to highlight the findings that indicate the client is stable for discharge.

The client has rested well throughout the night with a continuous positive airway pressure (CPAP) device in place. Sequential devices are in place for venous thromboembolism prevention. The client ambulated 100 yards (91 meters) last night and 200 yards (183 meters) this morning. She reports pain rating of 2 on 0 to 10 scale, located in the abdomen, described as aching. She has tolerated fluids throughout the night with no nausea or vomiting.

Assessment findings

Neurological Alert and oriented times 4.

Cardiovascular WNL.

Respiratory WNL.

Gastrointestinal/Genitourinary Voided twice throughout night, urine clear amber in appearance. Reports no dysuria. No bowel movement but the client is passing gas.

Integumentary 4 abdominal incisions from laparoscopic procedure sealed with surgical glue. No drainage, redness, or edema present.

Musculoskeletal Reported chronic knee pain. 5+ strength in bilateral upper extremities, 5+ strength in bilateral lower extremities.

An unlicensed assistive personnel (UAP) is assigned to provide personal care for a client who is prescribed bedrest with bedside commode use. The UAP reports to the nurse that the client's obesity makes it difficult to safely assist the client in transferring from the bed to the bedside commode. How should the nurse respond?

The nurse is caring for a client with the sexually transmitted infection (STI) genital herpes. The client reports having had prior sexually transmitted infections. Which response should the nurse provide?

A client who is one day postpartum reports that her baby cannot latch onto the breast. The nurse observes that the client's nipples are inverted. Which action should the nurse implement?

On admission to the emergency department, a client who was diagnosed with bipolar disorder 3 years ago reports taking a handful of medications this morning and left a suicide note for the family. Which information is most important for the nurse to obtain?

The nurse is conducting intake interviews of children at a city clinic. Which child is most susceptible to contracting lead poisoning?

A client receives a prescription for itraconazole. Which statement made by the client requires additional instruction by the nurse?