Question 1 of 5.

Extract:The nurse in the emergency department (ED) is caring for a 26-year-old female client. Item 6 of 6 • History and Physical 1702: The client reports a headache that has persisted for 48 hours. She describes the pain as constant, throbbing, and behind her left eye. She states that in the past six months, these headaches have occurred two to three times a month. The client reports visual disturbances, including flashes of light and blurred vision, often precede headaches. During the headache episodes, she experiences nausea, photophobia, and phonophobia. She notes that stress, lack of sleep, and certain foods such as chocolate seem to trigger the headaches. Over-the-counter pain relievers provide minimal relief. Her spouse reports new symptoms, stating that she became confused earlier in the day, had difficulty speaking, and had right arm weakness, all of which resolved before she arrived at the ED. Medical history of generalized anxiety and panic disorder for which she takes escitalopram 20 mg p.o. daily and buspirone 15 mg p.o. daily. Family history of ischemic stroke, hypertension, and diabetes mellitus. Physical Examination Neurological exam: Steady gait and cranial nerves grossly intact. Phonophobia. Pupils: 3 mm and brisk with some tearing in both eyes. Sensitive to pen light. Head and neck examination: Denies sinus pain and full cervical range of motion. Integumentary: Skin warm to touch and pale pink in tone. Cardiovascular: Peripheral pulses 2+ and no peripheral edema. Respiratory: Clear lung sounds bilaterally. Gastrointestinal: Reports persistent nausea. Normoactive bowel sounds in all quadrants. No distention. Psych: Anxious and in moderate distress. Cooperative. Vital Signs: Blood pressure: 120/80 mmHg Heart rate: 72 bpm Respiratory rate: 16 Temperature: 98.6°F (37°C) Oxygen saturation: 98% on room air • Diagnostics Test Results Head Computed Tomography (CT) scan 1739: No acute intracranial hemorrhage, mass effect, or midline shift identified. The ventricles and sulci are within normal limits. No evidence of acute ischemic changes. • Nurses' Notes 1741: Client placed back in room following emergent CT scan of the head. The client is alert, fully oriented, cooperative, and slightly anxious. Reports 'throbbing' headache rated 7/10 on the Numerical Rating Scale. Endorses photophobia, requesting lights to be turned off. Glasgow coma scale is 15. Clear lung sounds bilaterally. Peripheral pulses 2+. Reports persistent nausea. Full range of motion in all extremities. A 20-gauge peripheral vascular access device was started in the left antecubital space.

The nurse makes a note in the nurses' notes and reviews the diagnostic test results. Complete the sentence below from the list of options. The client is most likely experiencing--------------------as evidenced by------------------and-----------------

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?