Lesson 3 case study

which clinical manifestations will the nurse expect when caring for a client with a diagnosis of pulmonary edema? SATA

*- crackles* *- coughing* *- orthopnea* - yellow sputum *- anxiety* - dependent edema *- restlessness* *- lethargy*

which a client with heart failure is seen in the clinic with new onset ankle edema, the nurse would question the client about which lifestyle factor that may have contributed to the ankle swelling? SATA

*- intake of salty foods* *- increased fluid consumption* - dietary fat intake *- medication compliance* - family stresses *- recent travel* *- alcohol intake* - increased physical activity

which finding would the nurse expect when assessing a client with peripheral arterial disease (PAD)? SATA

*- pallor of feet* - warm extremities *- ulcers on the toes* *- delayed capillary refill* - thick, hardened skin *- hair loss to lower extremities* *- muscle atrophy* *- intermittent claudication*

when a client develops internal bleeding after abdominal surgery which clinical manifestation would the nurse expect the client to exhibit? SATA

*- pallor* - polyuria * - decreased mean arterial pressure (MAP)* - bradypnea *- tachycardia* - hypertension - increased pulse pressure - warm skin temperature

when assessing a client with varicose veins, which clinical manifestations would the nurse expect to find? SATA

*- presence of ankle edema* *- increased leg fatigue* - diminished peripheral pulses * - report of leg fullness and pruritus* - leg pain with activity that resolves with rest - no hair on lower extremities - thickened toenails - pallor to bilateral lower extremities

select the 5 assessment findings that are consistent with acute rheumatic fever

- murmur - opening snap - joint pain - painless nodules over elbows - previous sore throat and upper respiratory infections

based on the information over the time period provided, review the changes in the assessment data and click to highlight the findings that would indicate the client is progressing as expected.

- sinus tachycardia without any arrhythmias - few crackles noted in right lower lung field - +3 pitting edema in bilateral lower extremities - heart rate of 102 bpm - blood pressure of 138/80

the client understands the teaching by stating that ______, _______, and ______ indicate a reoccurrence of a streptococcal pharyngitis infection.

- sudden onset of sore throat - swollen lymph nodes - drainage in back of throat

chose most likely option for classification and client teaching

PCN: beta-lactam antimicrobial; you will be watched closely for 15 minutes after admission. Naproxen: NSAID; take with food or milk echocardiogram: noninvasive; sound waves are used to produce images electrocardiogram: electrodes will be placed on arms and legs

the nurse determines the priority is to ______ due to _______

administer the penicillin Group A beta-hemolytic streptococci infection

A 19-year-old female client presents to the emergency department (ED) with headache, shortness of breath, and joint pain 3 weeks after an upper respiratory tract infection. She states that she has no insurance and did not seek treatment because she is a college student and has no money for a doctor's appointment or medication. She tells the nurse, "I am tired all the time since I had this sore throat, and my wrists hurt." On further questioning, she also reports epigastric discomfort and constipation. On examination, the client has painless nodules over both elbows, an opening snap, split S2, and a murmur heard best in the area of the mitral valve. Vital signs: Temperature 101.6°F (38.7°C), heart rate of 104 beats per minute (bpm), respiratory rate of 24 breaths per minute, blood pressure of 110/72 mmHg, and pulse oximetry reading of 94%.

condition: chlorea clinical finding: sudden, purposeless non-repetitive movements

for each body system, click to specify the potential nursing intervention that would be appropriate for the care of the client

neurologic: monitor for aimless, involuntary movements integumentary: maintain hydration status cardiovascular: auscultate for a pericardial friction rub; encourage rest periods.