RN 3.0 Clinical Judgment Practice 2

A nurse is caring for a child in a prenatal clinic. Exhibit 1 Exhibit 2 Exhibit 3 Exhibit 4 Drag 1 condition and 1 client finding to fill in each blank in the following sentence. The client is at risk for developing ____________ due to ____________.

- At risk for developing: preeclampsia - Due to: blood pressure When analyzing cues, the nurse should note that gestational hypertension is a systolic blood pressure greater than 140 mm Hg or a diastolic blood pressure greater than 90 mm Hg for two occasions. Approximately 25% to 50% of client's who have gestational hypertension will develop preeclampsia. The nurse should monitor this client for clinical manifestations of preeclampsia, such as proteinuria greater or equal to 1 plus, hyperactive reflexes, visual disturbances, severe headaches, and right upper quadrant abdominal pain.

A nurse is caring for an infant in a clinic. Exhibit 1 Exhibit 2 Drag words from the choices below to fill in each blank in the following sentence. The nurse should follow up on _____________ and ______________. - BP - Temp - Weight - Heart rate - Verbal skills - Height - Respiratory rate - Fine motor skills - Gross motor skills

- Gross motor skills - Verbal skills When recognizing cues, the nurse should follow up on the infant's gross motor developmental skills and the infant's verbal skills. At 6 months of age, the infant should be able to sit with a straight back and have no head lag when pulling into a sitting position. The infant should also be able to imitate sounds and babble sounds such as "ma, mu, da, di, and hi". Both the infant's gross motor and verbal skills are delayed and need follow up by the nurse.

A nurse in a clinic is caring for an infant at the 6-month well-child visit. Exhibit 1 Exhibit 2 Exhibit 3 Select the 4 findings that require immediate follow-up. - Head circumference - Heart rate - Inability to pick up objects - Head lag - Irritability - Fontanel findings - VP shunt line - Respiratory rate

- Head circumference - Fontanel findings - Head lag - Irritability

A nurse on a medical surgical floor is caring for a newly admitted client following a motor vehicle crash. Exhibit 1 Exhibit 2 Exhibit 3 Exhibit 4 Which of the following actions should the nurse take? Select all that apply. - Provide a stimulating environment for the client. - Delegate to have an AP in the room. - Report the client's behavior to the provider. - Request a prescription for lorazepam. - Assess the client's history of alcohol use. - Offer orange juice to the client. - Keep the room dark. - Implement seizure precautions.

- Implement seizure precautions - Assess the client's history of alcohol use - Delegate to have an AP in the room - Report the client's behavior to the provider - Offer orange juice to the client - Request a prescription for lorazepam When taking action, the nurse should implement seizure precautions for a client who is experiencing withdrawals from alcohol because of the risk for seizures and alcohol withdrawal delirium. Withdrawal seizures can occur 12 to 24 hr after the cessation of alcohol. The nurse should assess the client's history of alcohol use because the client is exhibiting manifestations of alcohol withdrawal such as vital sign changes, agitation, nausea, and vomiting. The nurse should delegate for an AP to stay with the client to orient the client to reality if needed and to assist in keeping the client calm. The nurse should report the client's change in behavior to the provider to obtain the needed prescriptions to effectively care and treat the client. The nurse should offer orange juice or other sources of carbohydrates to prevent hypoglycemia because alcohol depletes the liver glucagon stores. The nurse should request a prescription for lorazepam to assist the client to relax and promote sleep to prevent peripheral vascular collapse.

A nurse is caring for a client who is newly admitted to the hospital. Exhibit 1 Exhibit 2 Exhibit 3 Exhibit 4 Complete the following sentence by using the list of options. The nurse should first _______________ followed by ________________.

- Increase Oxygen - Administer a bronchodilator After recognizing cues and analyzing the client's status, the nurse should identify that the client is having difficulty breathing as evidenced by shortness of breath, decreased oxygen saturations, and tachypnea. Using the airway, breathing, circulation priority setting framework to prioritize actions, the nurse should first increase the client's oxygen because the client's oxygen saturations are below expected reference range followed by administering a bronchodilator to increase the client's oxygenation.

A nurse is caring for a client in a clinic. Exhibit 1 Exhibit 2 Exhibit 3 Exhibit 4 Exhibit 5 Click to highlight the information the nurse should include in the educational material for the client. To deselect information, click on the information again. - Limit sodium intake to less than 1,500 mg/day - Walk daily at least 30 min - Limit cholesterol intake to 500 mg/day - Monitor blood pressure daily - Discuss options to eliminate tobacco use - Saturated fats should be not more than 10% of daily calorie intake - Take medication every morning before breakfast

- Limit sodium intake to less than 1,500 mg/day - Walk daily at least 30 min - Monitor blood pressure daily - Discuss options to eliminate tobacco use When generating solutions, the nurse should teach a client who has metabolic syndrome to limit sodium intake to decrease the risk of coronary artery disease. The nurse should teach a client who is obese to walk daily at least 30 min with a 10-min warm up and 5-min cool down to assist with weight loss. The nurse should teach the client to monitor their blood pressure daily and report elevated findings to their provider. The nurse should explore options to eliminate tobacco use for a client who has metabolic syndrome to decrease the risk of coronary artery disease.

A nurse is caring for a client in a clinic. Exhibit 1 Complete the following sentence by using the list of options. The nurse should first evaluate the client's ______________ as evidenced by the client's ____________________.

- risk for harming themselves - report of hopelessness When prioritizing hypotheses, the nurse should evaluate the risk for the client to harm themselves due to the client's report of hopelessness. Risk for suicide is increased when depression is accompanied with a loss, feelings of hopelessness, and a history of suicide attempts. A client who has suicidal ideations and a plan to harm themselves is an emergency and the nurse should intervene immediately.

A nurse is caring for a newly admitted 2-year-old toddler. Exhibit 1 Exhibit 2 Exhibit 3 Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Actions to take: - Prepare the toddler for an MRI of the abdomen - Monitor Vital signs every hour Condition: - Wilm's tumors Parameter to Monitor: - Hypertension - Manifestation of anemia Upon recognizing and analyzing cues of a unilateral mass on the child's abdomen, the nurse's priority hypotheses is that the client most likely has a Wilm's tumor and it is important to generate solutions and take actions to prepare the client for further testing to confirm the diagnosis. Therefore, the nurse should prepare the toddler for an MRI of the abdomen and monitor vital signs frequently. Wilm's tumors are more common with children who have a congenital anomalies. Clinical manifestations of a Wilm's tumor include a unilateral mass on the child's abdomen. Some children experience pain and fever. Other manifestations, such as shortness of breath and anemia, would appear if metastasis of the tumor has occurred. The nurse should monitor the toddler's blood pressure for hypertension, which would indicate excess renin excretion from the tumor and manifestations of anemia which would indicate a hemorrhage within the tumor.