Question 1 of 5.

Extract:The nurse in the emergency department (ED) is caring for a 20-year-old female client Item 6 of 6 ED Triage Note History And Physical Physician Orders 0912: Client was brought to the ED by her two college roommates 'because she was not acting right.' The roommate reports that she went to bed the night before reporting stiffness in her neck and a headache. She attributed it to being under pressure with final exams and having poor sleep the previous several days. The client apparently took non-prescribed lorazepam from another roommate to assist her with sleep. The roommate reported recently having influenza and is unsure if she became infected. It is reported that she declined the influenza vaccination when it was offered on campus. The roommate reports waking her with physical stimuli and found her diaphoretic, hot to touch, and mumbling, saying she did not feel well. Vital signs: T 103.4° F (39.7° C), P 112, RR 12, BP 116/86, pulse oximetry 95% on room air.

Click to highlight the findings below that indicate a worsening of the client's status: The client is lethargic and makes no purposeful movements. Does not respond to physical stimuli. Glasgow coma scale 10. Peripheral pulses 2+. The client's skin is pale and dry. Petechial rash on the torso. Vital signs: T 100.4° F (38° C), P 101, RR 12, BP 117/88, pulse oximetry reading 95%.

Question 2 of 5.

The nurse is caring for an 82-year-old male client admitted to the hospital for pneumonia. Which of the following findings may indicate a change in mental status?

Question 3 of 5.

The nurse is caring for a client following cervical spinal surgery. Which of the following assessments would require follow-up?

Question 4 of 5.

Extract:The following scenario applies to the next 1 items The nurse is caring for a 71-year-old female in the emergency department (ED) Item 1 of 1 Nurses' Note Diagnostics 1425: 71-year-old female arrives via EMS with a concern about a stroke. At approximately 1350 a client was at lunch with her family and suddenly stopped talking and fell to the right side. The client was unable to speak or follow verbal commands on the scene. Vital signs on arrival: 98.7° F (37.1° C), P 88, RR 18, BP 182/96. The client can blink her eyes and cannot follow verbal commands or express words. She is instructed to move each extremity but does not make any movement. Pupils are equal, round, and reactive to light. Right-sided facial drooping was noted. The client has a medical history of osteoarthritis, hypertension, and atrial fibrillation. 1427: A stroke alert was initiated at this time, and the client was transported to radiology for a STAT CT scan. 1438: Computed tomography scan completed. Physician at bedside evaluating the client and the results. 1444: Physician gave a verbal order for alteplase 0.9 mg/kg intravenous (IV) infuse over sixty minutes with a 10% alteplase bolus dosage given over one minute The nurse reviews the nurses' note entries from 1425, 1427, 1438, and 1444 and plans care for this client indicated

For each potential nursing intervention, click to specify if the intervention is indicated or not Indicated:

Question 5 of 5.

The nurse is discussing biological clocks with another nurse. What term is used to describe a human's innate biological clock relating to daytime and nighttime wakefulness and activity?