0800:
Client is alert and oriented. Breath sounds are clear and present throughout. Denies
tobacco use. Client lives in a one-story house with their child. Client reports they just
returned from an 8-hr car trip. Client eats a high fiber diet and drinks 1,800 mL of
fluid/day.
1000:
2.5 cm x 2.5 cm (1 in x 1 in) reddened area noted on client's left calf.
0800:
Temperature 38° C (100.4° F)
Blood pressure 114/50 mm Hg
Heart rate 96/min
Respiratory rate 20/min
SaO2 95% on room air
The client is at an increased risk for developing
due to
,Give this one a try later!
Deep vein thrombosis is correct. The client reports they just returned from
an 8-hr car trip. Extended periods of immobility place the client at an
increased risk for a deep vein thrombosis.
Recent car ride is correct. The client reports they just returned from an 8-
hr car trip. Extended periods of immobility place the client at an increased
risk for a deep vein thrombosis.
Medical History
1600:
Client brought to facility by adult grandchild who found the client on the floor of their
living room "passed out from drinking." Client has 5.1-cm (2-in) laceration on forehead
with dried blood present. Grandchild states client "has been drinking my entire life. I
don't know how they are still alive."
Plan:
Admit for alcohol use disorder, observe for alcohol withdrawal.
Diagnostic Results
1800:
Blood alcohol 360 mg/dL (0 to 50 mg/dL)
CBC:
WBC count 6,500/mm3 (5,000 to 10,000/mm3)
RBC count 4.0 (4.2 to 5.4)
Hemoglobin 11 g/dL (12 to 16 g/dL)
Hematocrit 33% (37% to 47%)
Platelet count 35,000/mm3 (150,000 to 400,000/mm3)
Albumin 3.5 g/dL (3.5 to 5 g/dL)
Ammonia 79 mcg/dL (10 to 80 mcg/dL)
The client is at highest risk for developing
_______________________
as evidenced by the client's
_______________________
,Give this one a try later!
Drop down 1
Bleeding is correct. The client is at highest risk for bleeding due to a
platelet count that is less than the expected reference range. Alcohol
toxicity impairs platelet production, causing thrombocytopenia and an
increased risk for hemorrhage.
Drop down 2
Platelet count is correct. The client is at highest risk for bleeding due to a
platelet count that is less than the expected reference range. Alcohol
toxicity impairs platelet production, causing thrombocytopenia and an
increased risk for hemorrhage.
A nurse is caring for a young adult.
Vital Signs
BP: 92/50 mm Hg
Heart rate: 56/min
Respiratory rate: 14/min
Temperature: 36.2° C (97.2° F) tympanic
SpO2: 96% room air
Height: 165.1 cm (65 in)
Weight: 45.4 kg (100 lb)
BMI: 16.6
Nurses Notes
Client presents with a report of anxiety and obsessive thoughts. Client has a flat affect
and avoids eye contact. Client noted to have lanugo and skin is cool to palpation.
Client reports constipation and hair loss. Client works full-time at an insurance office
and attends college part-time. Client also reports smoking "a few" cigarettes and
drinking alcohol 2 or 3 weekends a month. Client denies history of mental illness,
medical history unremarkable except for recurrent otitis media as a child.
Give this one a try later!
, Actions to Take
- observe the client for 1 hr after meals
- check the client's vital signs three times per day
Potential Condition
- anorexia nervosa
Parameters to Monitor
- client's daily morning weight
- potassium level
The nurse should observe the client for 1 hr after meals and check the
client's vital signs three times per day because the client is most likely
experiencing anorexia nervosa as evidenced by the client's preoccupation
with food, abnormal laboratory values, and low BMI.
The nurse should monitor the client's daily morning weight and potassium
level because being significantly underweight can cause electrolyte
imbalances, which can lead to cardiovascular collapse.
A nurse is caring for a client in the labor room.
Medical History
Gravida 2 Para 1
38 weeks gestation
Pregnancy complicated by gestational diabetes and hydramnios.
Spontaneous vaginal delivery 1 year ago.
No significant past medical history.
No history of surgeries.
Spontaneous onset of labor
Nurses Notes
1020:
Client pushing effectively. Crowning. Provider present at bedside.
Contraction pattern: occurring every 4- 5 min; lasting 75-90 seconds; palpate strong.
Fetal heart rate 150/min. Average variability. Spontaneous accelerations noted.
Variable decelerations noted when pushing.
1025:
Client is alert and oriented. Breath sounds are clear and present throughout. Denies
tobacco use. Client lives in a one-story house with their child. Client reports they just
returned from an 8-hr car trip. Client eats a high fiber diet and drinks 1,800 mL of
fluid/day.
1000:
2.5 cm x 2.5 cm (1 in x 1 in) reddened area noted on client's left calf.
0800:
Temperature 38° C (100.4° F)
Blood pressure 114/50 mm Hg
Heart rate 96/min
Respiratory rate 20/min
SaO2 95% on room air
The client is at an increased risk for developing
due to
,Give this one a try later!
Deep vein thrombosis is correct. The client reports they just returned from
an 8-hr car trip. Extended periods of immobility place the client at an
increased risk for a deep vein thrombosis.
Recent car ride is correct. The client reports they just returned from an 8-
hr car trip. Extended periods of immobility place the client at an increased
risk for a deep vein thrombosis.
Medical History
1600:
Client brought to facility by adult grandchild who found the client on the floor of their
living room "passed out from drinking." Client has 5.1-cm (2-in) laceration on forehead
with dried blood present. Grandchild states client "has been drinking my entire life. I
don't know how they are still alive."
Plan:
Admit for alcohol use disorder, observe for alcohol withdrawal.
Diagnostic Results
1800:
Blood alcohol 360 mg/dL (0 to 50 mg/dL)
CBC:
WBC count 6,500/mm3 (5,000 to 10,000/mm3)
RBC count 4.0 (4.2 to 5.4)
Hemoglobin 11 g/dL (12 to 16 g/dL)
Hematocrit 33% (37% to 47%)
Platelet count 35,000/mm3 (150,000 to 400,000/mm3)
Albumin 3.5 g/dL (3.5 to 5 g/dL)
Ammonia 79 mcg/dL (10 to 80 mcg/dL)
The client is at highest risk for developing
_______________________
as evidenced by the client's
_______________________
,Give this one a try later!
Drop down 1
Bleeding is correct. The client is at highest risk for bleeding due to a
platelet count that is less than the expected reference range. Alcohol
toxicity impairs platelet production, causing thrombocytopenia and an
increased risk for hemorrhage.
Drop down 2
Platelet count is correct. The client is at highest risk for bleeding due to a
platelet count that is less than the expected reference range. Alcohol
toxicity impairs platelet production, causing thrombocytopenia and an
increased risk for hemorrhage.
A nurse is caring for a young adult.
Vital Signs
BP: 92/50 mm Hg
Heart rate: 56/min
Respiratory rate: 14/min
Temperature: 36.2° C (97.2° F) tympanic
SpO2: 96% room air
Height: 165.1 cm (65 in)
Weight: 45.4 kg (100 lb)
BMI: 16.6
Nurses Notes
Client presents with a report of anxiety and obsessive thoughts. Client has a flat affect
and avoids eye contact. Client noted to have lanugo and skin is cool to palpation.
Client reports constipation and hair loss. Client works full-time at an insurance office
and attends college part-time. Client also reports smoking "a few" cigarettes and
drinking alcohol 2 or 3 weekends a month. Client denies history of mental illness,
medical history unremarkable except for recurrent otitis media as a child.
Give this one a try later!
, Actions to Take
- observe the client for 1 hr after meals
- check the client's vital signs three times per day
Potential Condition
- anorexia nervosa
Parameters to Monitor
- client's daily morning weight
- potassium level
The nurse should observe the client for 1 hr after meals and check the
client's vital signs three times per day because the client is most likely
experiencing anorexia nervosa as evidenced by the client's preoccupation
with food, abnormal laboratory values, and low BMI.
The nurse should monitor the client's daily morning weight and potassium
level because being significantly underweight can cause electrolyte
imbalances, which can lead to cardiovascular collapse.
A nurse is caring for a client in the labor room.
Medical History
Gravida 2 Para 1
38 weeks gestation
Pregnancy complicated by gestational diabetes and hydramnios.
Spontaneous vaginal delivery 1 year ago.
No significant past medical history.
No history of surgeries.
Spontaneous onset of labor
Nurses Notes
1020:
Client pushing effectively. Crowning. Provider present at bedside.
Contraction pattern: occurring every 4- 5 min; lasting 75-90 seconds; palpate strong.
Fetal heart rate 150/min. Average variability. Spontaneous accelerations noted.
Variable decelerations noted when pushing.
1025:
