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A nurse is assessing a client who has hyperthyroidism. The nurse should expect the client to report which of the following manifestations?

A nurse is caring for a 73-year-old client in the emergency department (ED).

Medical History: Client was brought to the ED by their family member due to mental status changes. The family member reports that they visit the client every other day, and today the client did not initially realize who they were until several minutes after talking with them. The client has diabetes mellitus and takes insulin daily. A wound is noted on the right foot.

Nurses Notes: Family member reports that the client did not initially realize who they were when they went to visit. Client is currently somnolent but rouses to verbal stimuli and is oriented to person. Glasgow coma score is 13 and Modified Early Warning System (MEWS) score is 6. Respirations are even, unlabored, and deep, with few crackles noted in lung bases bilaterally with auscultation. Mucous membranes are dry and pink. Abdomen soft with hypoactive bowel sounds. Radial and pedal pulses are palpable, no edema noted. Skin is warm and dry. The right foot has a 2.5 cm x 3.3 cm (1 in x 1.3 in) superficial wound to the ball of the foot. The wound is moist with a scant amount of purulent drainage. Client stated they stepped on something last week while walking but did not notice a wound had occurred.

Client’s family member reports that the client takes 10 units of regular insulin subcutaneously every morning and 5 units every evening with the last dose taken this morning. Also states that the client took two aspirin yesterday for a headache.

Vital Signs:

• Temperature: 38.5°C (101.3°F)
• Pulse: 110/min
• Blood pressure: 98/60 mm Hg
• Respiratory rate: 26/min
• Oxygen saturation: 93% on 2 L nasal cannula
•  

Diagnostic Results:

• RBC count: 5.0 (Male 4.7 to 6.1)
• WBC count: 9,500/mm³ (5,000 to 10,000/mm³)
• Platelets: 97,000/mm³ (150,000 to 400,000/mm³)
• Hemoglobin: 15 g/dL (Male 14 to 18 g/dL)
• Hematocrit: 45% (Male 42% to 52%; Female 37% to 47%)
• Glucose: 186 mg/dL (74 to 106 mg/dL)

It has been identified that the client is in sepsis. Select the 4 actions that the nurse should complete in the first hour to manage sepsis and prevent further complications:

A nurse is monitoring a client who is receiving a blood transfusion. Which of the following findings indicates an allergic transfusion reaction?

A nurse is caring for a client who suspects recent exposure to inhalation anthrax. Which of the following findings indicate possible exposure?

A nurse is caring for a patient on a medical-surgical unit.

Medical History:

•  
• Day 1:                                                                                                                        
  • Parkinson’s Disease
  • Heart failure

Medication Administration Record:

•  
• Day 1:                                                                                                                     
  • Furosemide 40 mg po bid
  • Carbidopa/Levodopa 25 mg/100 mg po tid

Vital Signs:

•  
• Day 1:                                                                                                                    
  • Temperature: 37.2°C (99°F)
  • BP: 128/56 mm Hg sitting, 92/40 mm Hg standing
  • Heart rate: 66/min
  • Respiratory rate: 18/min
  • Pulse oximetry: 96% on room air (95% to 100%)

Diagnostic Results:

•  
• Day 1:                                                                                                                    
  • Hct: 38% (37% to 47%)
  • Hgb: 13 g/dL (12 g/dL to 16 g/dL)
  • WBC: 6,500/mm³ (5,000 to 10,000/mm³)
  • Potassium: 3.5 mEq/L (3.5 mEq/L to 5 mEq/L)
•  
• Day 2:                                                                                                                    
  • Hct: 39% (37% to 47%)
  • Hgb: 14 g/dL (12 g/dL to 16 g/dL)
  • WBC: 7,000/mm³ (5,000 to 10,000/mm³)
  • Potassium: 3.0 mEq/L (3.5 mEq/L to 5 mEq/L)

A nurse is performing a fall risk assessment on a patient. Which of the following findings indicate that the patient is at increased risk for falls? Select all that apply

A nurse is planning care for a client who is 2 hours postoperative following a transurethral resection of the prostate. The client is receiving continuous bladder irrigation. Which of the following interventions should the nurse include?

A nurse is caring for a client who is scheduled to have surgery. In preparing the client for surgery, which of the following actions is considered outside the nurse’s responsibilities?

A nurse is caring for a client who is 2 hours postoperative after having a total abdominal hysterectomy.

Nurses’ Notes

0800: Lungs clear to auscultation in all lobes anterior and posterior. 0.9% sodium chloride infusing into left forearm at 125 mL/hr. Bowel sounds hypoactive in all four quadrants. Abdomen soft and tender to palpation. Abdominal dressing dry and intact. Scant vaginal bleeding observed. Intermittent pneumatic compression devices observed on bilateral lower extremities. Foley catheter intact and patent, draining to bedside bag. Instructed client to turn and cough every 2 hours while awake. Demonstrated splinting incision with pillow when coughing.

1000: Attempted to assist client with turning and coughing. Client reports that moving is too painful and refuses to change positions or cough. Client has had visitor remove intermittent pneumatic compression devices and declines having them replaced, stating, “They make my legs too hot.” Reinforced to client the importance of turning, coughing, and wearing intermittent pneumatic compression devices. Client continues refusing to turn, cough, or replace intermittent pneumatic compression devices.

Drag words from the choices below to fill in each blank in the following sentence.

The client is at risk for developing ­­­­­­­­­­­­_____________(Target 1), ____________(Target 2) and _____________( Target 3).

A nurse is discussing the norming stage of the group development process with a student nurse. Which of the following statements by the student indicates understanding of the discussion?

A nurse enters a client’s room and finds him on the floor in the clonic phase of a tonic-clonic seizure. Which of the following actions should the nurse take?

A nurse is completing a physical assessment of a client who has early osteoarthritis. Which of the following manifestations should the nurse expect?