n n n
Abnursebisbcaringbforbab5-year-oldbchild
n n n n n n n
PhysicalbExamination: n
1510:
Uponbvisualbinspection,bthroatbisbinflamed,btonsilsbappearbpink,breddenedband
n n n n n n n n n n
bepiglottis is bedematous band bcherry bred bin bappearance. bSkin bappears bpale. bStridor
n n n n n n n n n n n n
bnoted bupon inspiration bwith bdiminished bbilateral blung bsounds.
n n n n n n n n
Nurse'sbNotes: n
1500
Childbaccompaniedbtobemergencybdepartment bbybcaregiver.bCaregiverbstatesbchild
n n n n n n n n n
bhasba sore bthroatband breports bthe bchild bhas b"pain bon bswallowing" band bdenies
n n n n n n n n n n n n n n
bcough. bChild bis agitated band blean b- bcorrect banswer.
n n Condition:bEpiglottis n n n n n n n n
Actions:bInitiatebdropletbprecautionsbandbrequestbabprescriptionbforbIVbantibiotics
n n n n n n n n n n n
Monitors: bBreath bsounds band btemperature
n n n n n
Thebnursebshouldbanticipate binitiatingbdropletbprecautionsbandbrequestingba
n n n n n n n n n n
bprescription forbIV bantibiotics.bThebchild bisbmost blikelybexperiencing bepiglottis
n n n n n n n n n n n n
bbecausebofbthebclinical manifestationsbofbabhighbfever,binflammationbandbredness
n n n n n n n n n n n n
bofbthebthroat,bpalebskin,bstridor withbinspiration,bpainfulbswallowing,
n n n n n n n n n n
bnobcough,bisbsitting bin btripod bposition, band bdrooling. The bnurse bshould bmonitor bthe
n n n n n n n n n n n n n n
bchild's btemperature band bbreath bsounds.
n n n n n
Abnursebisbcaringbforbabclientbwhobisbonbthebspinalbcordbinjuryb(SCI)bunit
n n n n n n n n n n n n n n n
Nurses'bNotes n
Dayb3,b1700
n n n
ClientbadmittedbtobSCIbunitb3bdaysbagobfollowingbC7binjury.bSkinbisbcool,bpale,band bdrybto
n n n n n n n n n n n n n n n n n
ntouch.bRespirationsbeasybandbunlabored.bLungbsoundsbdiminishedbinblowerblobes.
n n n n n n n n n n
Abdomenbsoftband bnondistendedbwith bactive bbowelbsounds.bClient bpassed babsmall
n n n n n n n n n n nn
namountbofbhardbformedbstoolbthisbAM.bIndwellingburinarybcatheterbdrainingbclear
n n n n n n n n n n n
byellow urine. bDeepbtendonbreflexes b(DTR)bare bbicepsb1+, btricepsb1+, bpab-
n n n n n n n n n n n n n
bcorrect banswer. n The
client bis bmost blikelybexperiencing bmanifestations bof bpneumonia band bautonomic
n n n n n n n n n
dysreflexia.
n
,Thebnursebshouldbanalyze bcuesbfrombthebclient'sbmanifestationsbandbdetermine bthat
n n n n n n n n n n n
bthe client bisbmost blikelybexperiencing bmanifestationsbofbpneumonia bandbautonomic
n n n n n n n n n n n
ndysreflexia.bAbclientbwhobhasbabcervicalbSCIbisbatbriskbforbrespiratory bcomplications n n n n n n n n n n n n n
nbecausebspinalbinnervationbtobthebrespiratorybmusclesbisbdisrupted. n n n n n n n n
bAdventitiousbbreath soundsbinbtheblowerblobesbbilaterallyband ba bdecreasebin boxygen
n n n n n n n n n n n n n
bsaturation btobless bthan 92%bcanbindicate bpneumonia. bThe bclient's bsudden bincrease
n n n n n n n n n n nn n
bin bblood bpressure, bradycardia, bflushing bof bthe bskin babove bthe bareabofbthebinjury,
n n n n n n n n n n n n n n
bheadache,bandbblurred visionbarebmanifestationsbofbautonomic bdysreflexia, bwhich
n n n n n n n n n n
bcan bbe ba blife-threatening condition.
n n n n n
Abnursebisbcaringbforbabclientbwhobhasbabdominalbpain
n n n n n n n n n n
Nurses'bNotes n
0900
n
Clientbreportsblossbofbappetite,bweightbloss,bandbfatiguebforb1bweek.bReports
n n n n n n n n n n n n
babdominal pain,b6 bon babscale bfrom b0 bto b10, bfor b2bdays. bClient bis ba bperioperative
n n n n n n n n n n n n n n n n n
bnurse,breturnedb1 weekbagobfrombab2-weekbmissionbtripbtoban bunderdeveloped
n n n n n n n n n n n n n
bcountry
n
1200
Resultsbofbantibodybstudiesbobtained.bProviderbprescriptionbforbantiviralbmedication
n n n n n n n n n
pending.
n
PhysicalbExamination n
0930
n
Lungbsoundsbclearbbilaterally. bSkinbwarmbto btouchband bjaub-bcorrect banswer.
n n n n n n n n n n n n
Hepatitis
A:bClient'sbriskbfrombfecal-oralbtransmission,blaboratorybresults,bandbphysical bexamination
n n n n n n n n n n
n findings
HepatitisbB:bAntiviralbtreatment,blaboratorybresults,bclient'sbriskbfrombbloodborne
n n n n n n n n n
transmission, bphysical bexamination bfindings
n n n n
HepatitisbC:bAntiviralbtreatment,blaboratorybresults,bclient'sbriskbfrombbloodborne
n n n n n n n n n
transmission, band bphysical bexamination bfindings
n n n n n
When banalyzing bcues, bthe bnurse bshould brecognize bthat bmanifestationsbofbhepatitis bA,
n n n n n n n n n n n
nhepatitis bB, band bhepatitis bCbinclude bjaundice, byellowbsclerae, bright bupper bquandrant
n n n n n n n n n n n
bpain uponbpalpation, bdarkbyellowburine, band belevated bASTband bALT blevels. bWhen
n n n n n n n n n n n n n
banalyzing cues,bthebnursebshouldbalsobrecognizebthebclient'sbrisk
n n n n n n n n n n
bforbcontractingbhepatitisbAbthrough thebfecal-oralbroutebduringbrecentbtravelbtoban
n n n n n n n n n n n n n
bunderdeveloped bcountry band bthebclient's occupational briskbasba bperioperative bnurse
n n n n n n n n n n nn
bforbcontractingbhepatitis bBband bhepatitis bC through bbloodborne btransmission. bThe
n n n n n n n n n nn n
bnurse bshould brecognize bthat bthe bcurrent bstandard of bpractice bfor
n n n n n n n n n n
Abnursebisbcaringbforbabclientbonbabmedical-surgicalbunit
n n n n n n n n n n
,VitalbSigns n
0700
n
Temperatureb37.6bCb(99.7bF) n n n n
nHeart brate b100/min n n
Respiratory brate b22/min
n n n
Bloodbpressureb115/70 n n
bmmHg
n
Oxygenbsaturationb98%bonbroombair n n n n n
Nurses'bNotes n
1100
n
Client balert band boriented bto bperson, bplace,bandbtime. bClient bhad bepisode bof bdiarrhea,
n n n n n n n n n n n n n
nprovidedbperinealbcare.bNotedb2bcmbxb2bcmb(0.8binbxb0.8bin)bpainfulbedematousbarea
n n n n n n n n n n n n n n n n
bon sacrum. bClient brepositioned bevery b4 bhr. b- bcorrect banswer.
n n n n n n n n n n
Clickbtobhighlightbthe n n n
bfindings thatbrequire bfollowbup. bTobdeselect babfinding, bclickbonbthe bfindingbagain.
n n n n n n n n n n n n n
- Notedb2bcmbxb2bcmb(0.8binbxb0.8bin)bpainfulbedematousbareabonbsacrum
n n n n n n n n n n n n n n n
- Clientbrepositionedbeveryb4bhr n n n n
Whenbrecognizingbcues,bthebnursebshouldbdeterminebthatbthebclient'sbpainful
n n n n n n n n n n
bedematous areabonbtheirbsacrumbandbthatbthebclientbhasbonlybbeenbrepositioned
n n n n n n n n n n n n n
beveryb4bhrbrequires followbup.bThebclientbhasbmanifestationsbofbabpressurebinjury bthat
n n n n n n n n n n n n n n n
bneedbtobbebaddressed. Thebclient bshould bbebrepositioned bat bleast bevery b2 bhrbto
n n n n n n n n n n n n n n n
bpreventbworseningbofbthe pressurebinjurybandbtobrelievebpressurebfrombthebsacralbarea.
n n n n n n n n n n n n n n
Abnursebinbanboutpatientbmentalbhealthbclinicbisbcaringbforbabclient
n n n n n n n n n n n n
VitalbSigns n
3bmonthsbago
n n
Bloodbpressureb116/68 n
bmmHg Heartbrateb82/min
n n n n
Respiratory brate b16/min n n
Temperature b36.7 bC b(98.1
n n n n n
bF) SaO2b97%bonbroombair
n n n n n n
Today:
Bloodbpressureb128/76 n
bmmHg Heartbrateb104/min
n n n n
Respiratory brate b22/min
n n n
Temperature b37.4 b(99.4 bF)
n n n n
SaO2 b97% bon broom bair
n n n n n
Nurses'bNotes n
3bmonths bago
n n n
Client brecently badmitted bwith bnewbdiagnosis bof bschizophrenia. bReceived binpatient
n n n n n n n n n
treatment bforb10 bdays band bwas bdischarged b1 bweek bago. b- bcorrect banswer.
n n n n n n n n n n n n n
Selectbthe
b3 findingsbthatbrequirebimmediatebfollowbup:
n n n n n n
- Auditorybhallucinations
, - Speech
- Restlessness
Whenbrecognizing bcues, bthebnursebshouldbidentifybthatbthebfindings bof brestlessness,
n n n n n n n n n n nn
nauditory bhallucinations, band bpressured bspeech brequire bimmediate bfollowbup.bThese
n n n n n n n n n
findingsbarebindicationsbofbpsychosis.bThebnursebshouldbnotify bthe bprovider bfor
n n n n n n n n n n n n
badditional evaluation band btreatment.
n n n n
Abnursebisbcaringbforbabclientbwhobisbpostoperativebfollowingbcoronarybartery bbypass
n n n n n n n n n n n n n
surgery b(CABG)
n n
Laboratory
bResults 0630 n
Sodium b145 bmEq/L b(136 bto b145 bmEq/L) n n n n n nn
nPotassiumb3.2bmEq/Lb(3.5btob5bmEq/L) n n n n n n
nChlorideb116bmEq/Lb(98btob106 bmEq/L) n n n n n n
nBUN b24 bmg/dL b(10 bto b20bmg/dL) n n n n n n
Magnesiumb1.5bmEq/Lb(1.3
n n n n
btob2.1bmEq/L) Totalbcalcium b9 bmg/dL
n n n n n n n
b(9 bto b10.5 bmg/dL) Phosphate b4.6
n n n n n n n
bmg/dL b(3 bto b4.5 bmg/dL) Glucose b95
n n n n n n n
bmg/dL b(74 bto b106 bmg/dL)
n n n n n
WBCbcountb9,500/mm3b(5,000btob10,000/mm3)
n n n n n
Ib&bO
n n
0700 n
4bhrbinputb400bmL
n n n n
4bhrboutputb-bcorrectbanswer. Thebclientbisbatbgreatestbriskbforbdeveloping bdysrhythmias,
n n n n n n n n n n n n n n
n as bevidenced bby belectrolyte bimbalance.
n n n n
Thebnursebshouldbanalyzebcuesbtobdeterminebthebclientbisbatbgreatestbriskbfor bdeveloping
n n n n n n n n n n n n n n
ndysrhythmias brelatedbtobhypokalemia,basbevidencedbbybthe blaboratorybreportbandbthe n n n n n n n n n n n
nclient'sbreportbofbmusclebcramping. bPotassiumbandbmagnesiumbdepletion barebcommon
n n n n n n n n n n
nmanifestationsbinbclientsbwhobarebpostoperative bfollowingbCABG.bDuebtobmedicationbor n n n n n n n n n n n
hemodilation,bitbisbimportantbforbthebnursebtobcloselybmonitorbelectrolytes.
n n n n n n n n n n n
Abnursebisbcaringbforbabclientbwhobisbpregnantbinbthebacutebcarebsetting
n n n n n n n n n n n n n n
Nurses'bNotes n
1400 n
Clientbreportsbabconstantblowbdullbbackachebandbpainlessbabdominalbtighteningbfor bthe
n n n n n n n n n n n n
npastb3bhr.bDeniesbanybchangesbinbvaginalbdischarge.bExternalbfetalbmonitorbapplied.
n n n n n n n n n n n n
1430
Contractionbpattern:bcontractionsbeveryb4btob5bmin,blastingb30btob45bseconds, bpalpate n n n n n n n n n n n n n
mild bin bintensity
n n n