Physiological Adaptation

The 11-month-old, previously healthy infant is brought to the emergency department after becoming increasingly lethargic over the past 24 hours. The infant’s vital signs are notable for a temperature of 40.8°C, heart rate 138 bpm, respiratory rate 31, and blood pressure 84/50 mmHg. Upon assessment, the nurse notes sensitivity to light and sound, bulging anterior fontanelle, and significant resistance to turning the head. Place the interventions in the correct order.  

A 16-year-old boy is brought to the clinic by his mother with complaints of strange noises and movements. The boy states, “I can’t stand that I make this weird noise with my mouth. I can feel it coming, and I try to stop it for as long as I can, but eventually it just comes out. The other kids at school make fun of me. It’s so embarrassing.” The mother reports that the boy gets good grades and has no trouble concentrating at home when doing homework. Which information does the nurse give the patient and his mother about the medication he will be prescribed?  

The nurse is caring for a 57-year-old woman who is intubated and sedated in the post-anesthesia care unit following a radical hysterectomy. The patient remained stable throughout the 6 hour surgery during which she experienced a 2 L blood loss. The nurse has emptied the patient’s indwelling catheter every hour for the 3 hours the patient has been in the PACU with the following volumes: 54 mL, 23 mL, 12 mL, and 5 mL. Her heart rate is 112 bpm, oxygen saturation is 99%, and blood pressure is 82/54 mmHg. The nurse contacts the provider to report these findings and advocate for which initial order?  

The patient is brought to the emergency room after briefly losing consciousness. He states, “I feel like my heart has been racing for days now. I just assumed it was stress, but now it feels so much worse.” He is pale, diaphoretic, and tachypneic. His heart rate is 118 bpm and his blood pressure is 86/52 mmHg. An electrocardiogram shows an irregularly irregular RR interval without distinct P waves. The nurse prepares the patient for which intervention? 

The 48-year-old patient is brought via ambulance to the emergency room after being found unresponsive by her son. She has a prescription for transdermal fentanyl patches for treatment of cancer pain related to her breast cancer that has metastasized to her pelvis. The patient’s heart rate is 72 bpm, respiratory rate is 4 breaths per minute, and her oxygen saturation is 88%. Her arterial blood gas results are: pH 7.21, PaCO₂ 72 mmHg, PaO₂ 74, HCO₃¯ 23. A thorough assessment reveals 2 fentanyl patches on the patient’s skin. The nurse advocates for which initial action?  

The 23-year-old patient is brought to the emergency department after contacting emergency services to report profound weakness that started in his feet and worsened and spread cranially over the past few days. He reports severe diarrhea after a camping trip a week ago. Upon assessment, strength, sensation, and deep tendon reflexes are significantly reduced, with the lower extremities more severely affected than his upper extremities. Vital signs are normal and the patient seems to be breathing well. There is increased protein in the cerebrospinal fluid found after a lumbar puncture. The patient is admitted to the intensive care unit for further management and observation. The ICU nurse includes which interventions in the plan of care? Select all that apply.  

The 75-year-old patient presents to the emergency department complaining of a severe headache that is localized behind the right eye. The patient is nauseous and vomits upon standing. While wearing glasses, the visual acuity is 20/25 in the left eye and 20/110 in the right (records show it is normally also 20/25 corrected). Her left pupil is equal, round, and reactive to light and accommodation; it is measured at 3 mm. Her right pupil reacts only minimally to light and measures at 5 mm; it is round. The provider palpates the eye and reports that it is tense. Her heart rate is 102 bpm and blood pressure is 118/84 mmHg. The nurse anticipates providing which intervention first?  

The 50-year-old previously healthy patient complains of shortness of breath, especially on exertion or when laying down to sleep. She takes over-the-counter allergy medicine for seasonal allergies and melatonin to help her sleep sometimes. Her vital signs are heart rate of 64 bpm, respirations 22, oxygen saturation 99%, and blood pressure 114/68 mmHg. Her assessment is notable for crackles over the bilateral lung bases and a moderate diastolic apical murmur. Her electrocardiogram is normal. Her echocardiogram shows normal function of the left ventricle and severe stenosis of the mitral valve. The nurse provides which information to the patient?  

The 38-year-old patient who strictly adheres to a vegan diet complains of weakness and tingling in her lower extremities. She retains the strength in her lower extremities but proprioception is decreased.  Her complete blood count reveals a megaloblastic anemia. Which statement by the nurse is most appropriate? 

The 58-year-old patient presents to the emergency department complaining of worsening back pain that started a few days ago. He states, “I thought maybe I had slept wrong and gotten a spasm, but I’m not sure. I didn’t fall or get hit or anything. The ibuprofen I took definitely didn’t help.” His blood pressure is 174/96 mmHg and heart rate is 96 bpm. He reports being out of his antihypertensive medication for the past week while he was out of town. Other history is notable for arthritis in the hands and a 44-pack-year smoking history. He drinks socially but denies illicit drug use. Which assessment is most important? 

The 21-year-old intoxicated patient presents to the emergency department after sustaining an injury to the right hand during an altercation in a bar. He reports punching another individual in the face. An x-ray of the hand reveals a broken 4th proximal phalange and metacarpal. The corresponding knuckle has an open laceration. The nurse prepares the patient for which treatment?  

The patient with human immunodeficiency virus (HIV) presents with a disseminated rash. The nurse notes purple papules over the trunk, arms, and on mucous membranes. Some are scabbed. The patient’s CD4 count is 64. Although highly active antiretroviral therapy (HAART) has been prescribed, the patient reports being noncompliant because of intolerable side effects. The nurse suspects which infection is most responsible for this new rash? 

During the provider’s exam of the 6-hour-old neonate, the provider reports observing a red reflex in the neonate’s right eye, but not the left. The provider observes whiteness at the back of the eye. The nurse compiles information for the new parents about which procedure?  

The 59-year-old female reports vaginal bleeding. She experienced menarche at 12 years of age and menopause at 56. Endometrial carcinoma is found with endometrial biopsy. Further testing reveals no lymph node involvement or metastasis. The nurse prepares the patient for which initial therapy?  

The nurse witnesses a 19-year-old collapse while playing soccer. The individual is arousable but confused and irritable. The skin is warm, dry, and flushed. Which actions are most helpful? Select all that apply.  

The 20-year-old healthy soccer player is brought to the emergency department after collapsing at the end of a summer soccer game. The patient is lethargic and confused about the event. Upon assessment, the nurse notes flushed, dry skin that is warm to the touch. The oral mucosa is dry, as well. Vitals are as follows: temperature 40.7°C, heart rate 122 bpm, respiratory rate 20, and blood pressure 116/64 mmHg. Which order does the nurse carry out first?  

The 20-year-old healthy soccer player is brought to the emergency department after collapsing at the end of a summer soccer game. The patient is lethargic and confused about the event. Upon assessment, the nurse notes flushed, dry skin that is warm to the touch. The oral mucosa is dry, as well. Vitals are as follows: temperature 40.7°C, heart rate 122 bpm, respiratory rate 20, and blood pressure 116/64 mmHg. A rectal thermistor is inserted and aggressive cooling measures are instituted. After 30 minutes in the ice bath, the patient’s rectal temperature is 39.1°C and the ice is partially melted. Which action by the nurse is most important?  

The 20-year-old healthy soccer player is brought to the emergency department after collapsing at the end of a summer soccer game. The patient is lethargic and confused about the event. Upon assessment, the nurse notes flushed, dry skin that is warm to the touch. The oral mucosa is dry, as well. Vitals are as follows: temperature 40.7°C, heart rate 122 bpm, respiratory rate 20, and blood pressure 116/64 mm Hg. A rectal thermistor is inserted and aggressive cooling measures are instituted. After 30 minutes in the ice bath, the patient’s rectal temperature is 39.1°C and the ice is partially melted. The nurse notes the rectal thermistor has stopped working; there are no other rectal thermistors in the facility. Which action by the nurse is most appropriate? 

The nurse is most suspicious of glucose-6-phosphate dehydrogenase (G6PD) deficiency in which patient who presents with jaundice and fatigue after receiving an antimalarial drug?  

 The nurse is the first responder after a child is pulled unresponsive from the pool. There is no pulse and no breathing. The nurse sends someone for the AED, instructs another person to call 911, and begins chest compressions. By looking transversely at the chest, select the depth to which the nurse compresses the chest, if each line represents an inch of compression. 

The mother of the 7-week-old infant reports the baby has had fewer and fewer wet diapers and hasn’t stooled in 3 days despite having a ravenous appetite. The mother reports that the child has been vomiting with increasing force and volume over the past two weeks. The emesis just appears to be partially digested breastmilk and fluid. The infant appears well and vitals are normal. Upon palpation of the abdomen, a small, olive-shaped mass is appreciated. The nurse alerts the provider and prepares education for which procedure?  

The mother of the 7-week-old infant reports the baby has had fewer and fewer wet diapers and hasn’t stooled in 3 days despite having a ravenous appetite. The mother reports that the child has been vomiting with increasing force and volume over the past two weeks. The emesis just appears to be partially digested breastmilk and fluid. The infant appears well, but mucous membranes are dry, the child has a low-grade fever, and is tachycardic. Upon palpation of the abdomen, a small, olive-shaped mass is appreciated. A serum electrolyte panel reveals a sodium of 132, potassium of 2.7, chloride of 89, and a glucose of 92. The nurse performs which nursing action first? 

A 4-year-old child presents for a well-child visit. The parents report the child is doing well, has a good appetite, and has been meeting developmental milestones appropriately. Two months ago, the child was treated with antibiotics for an upper respiratory tract infection. Otherwise, the child is quite healthy. Upon assessment, the nurse notes a left-sided flank mass. The child denies urinary issues including pain or frequency, and the parents report that the child has had no incontinence episodes for a full year. The urinalysis is normal with the exception of 2+ blood. The nurse prepares to educate the family on which condition that most likely explains the child’s symptoms?  

The neonate is found to have a hemoglobin of 26 g/dL on the first day of life. Which additional findings does the nurse anticipate in this patient? Select all that apply.