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When inspecting the client’s skin, the nurse observes several areas of ecchymosis on the trunk and extremities. Which information in the client’s history requires additional follow-up by the nurse?

The nurse is performing an admission assessment for a client with pyelonephritis who has urgency and burning while urinating.
Which finding indicates an expected response when the nurse percusses the costovertebral angle?

Which assessment finding supports the client statement, “My feet swell all the time?”

A nurse is caring for a 45-year-old male client in the emergency department who sustained a fall from a ladder. The client has a closed and displaced fracture of the right ulna and radius. The nurse is monitoring the client closely for any changes in condition.

Exhibits

Nurses’ Notes (0800 hrs)

• The client is alert and oriented to person, place, time, and situation.
• The right forearm is visibly deformed with significant swelling and bruising.
• The client reports severe pain rated 10/10, described as sharp and throbbing.
• Capillary refill in the right hand is 4 seconds.
• The skin on the right forearm is warm to the touch.
• Radial pulse is 2+ and palpable.
• The client denies any numbness or tingling in the right hand.

Vital Signs (0800 hrs)

• Temperature: 37.2°C (99°F)
• Heart Rate: 88 bpm
• Blood Pressure: 138/82 mmHg
• Respiratory Rate: 18 breaths/min
• Oxygen Saturation: 98% on room air

Diagnostic Results (0800 hrs)

• X-ray results: Closed and displaced fracture of the right ulna and radius.
• Hemoglobin: 13.5 g/dL (Reference range: 13.8-17.2 g/dL)
• White Blood Cell Count: 8,000/mm³ (Reference range: 4,500-11,000/mm³)

Provider’s Prescriptions (0800 hrs)

• 0.9% sodium chloride IV infusion at 75 mL/hr
• Morphine sulfate 2 mg IV push STAT once
• Obtain cast cart
• Neurovascular assessment every hour for the first 24 hours

A nurse is caring for a 45-year-old male client in the emergency department with a closed and displaced fracture of the right ulna and radius. Based on the exhibits provided, what is the priority nursing action at this time?

A nurse is caring for a 57-year-old female client in the emergency department who presents with joint pain and stiffness in her hands. The client has a history of hypertension and type 2 diabetes.

Exhibits

Nurses’ Notes (0700hrs):

• The client reports experiencing joint pain and stiffness in her hands for the past few months.
• The pain is described as aching and is worse in the morning, lasting for about an hour before improving.
• The client mentions difficulty in performing daily tasks such as buttoning clothes and opening jars.
• There is visible swelling in the small joints of both hands.
• The client denies any recent trauma or injury to the hands.
• The client reports feeling fatigued and has had occasional low-grade fevers.
• The client is currently taking medication for hypertension and diabetes.

Medical History:

• Hypertension for 10 years, managed with medication.
• Type 2 diabetes for 5 years, managed with oral hypoglycemic agents.
• No known allergies.
• Family history of autoimmune diseases.

Vital Signs (0700hrs):

• Temperature: 37.8°C (100°F)
• Blood Pressure: 140/90 mmHg
• Heart Rate: 82 bpm
• Respiratory Rate: 18 breaths per minute
• Oxygen Saturation: 98% on room air

Physical Examination Results (0700hrs):

• Swelling and tenderness in the metacarpophalangeal and proximal interphalangeal joints of both hands.
• Limited range of motion in the affected joints.
• No deformities observed.
• Skin over the joints appears slightly erythematous.
• No signs of infection or injury.

Diagnostic Results (0700hrs):

• Complete Blood Count (CBC): WBC 8,000/mm³ (4,000-11,000/mm³), Hemoglobin 13.5 g/dL (12-16 g/dL), Platelets 250,000/mm³ (150,000-450,000/mm³)
• Erythrocyte Sedimentation Rate (ESR): 40 mm/hr (0-20 mm/hr)
• C-Reactive Protein (CRP): 15 mg/L (0-10 mg/L)
• Rheumatoid Factor (RF): Positive

A nurse is analyzing the assessment findings. Which findings are indicative of rheumatoid arthritis? Select all that apply.

An older adult male arrives at the healthcare center with lower abdominal discomfort and frequent urination. The nurse asks the client to provide a urine sample. After an extended period of time, the client returns with only a few drops of urine. Which action should the nurse implement?

While percussing the borders of the heart, the nurse picks up an area of dullness beginning at the 5th left intercostal space and moving upward to the 2nd left intercostal space at the sternal border. What do these findings indicate?

The nurse asks a female client about the proverb “Glass Houses,” and she replies, “It will break the windows.”. Which conclusion should be documented about this client’s response?

The nurse observes an older adult client walking aimlessly in the hallway and staring straight ahead with a blank expression. How should the nurse enter documentation of this finding in the client’s electronic medical record (EMR)?

During the admission assessment, a client admitted with chest pain reports having no breathing problems and no trouble sleeping at night. To obtain further data regarding possible orthopnea, which action should the nurse take?

When family members express their concern about their father’s recent memory loss, which assessment should the nurse suggest?