A 35-year-old client with a 5-year history of relapsing-remitting multiple sclerosis (MS) is admitted to the medical unit with new-onset lower extremity weakness, difficulty walking, and blurred vision in the right eye. The client states, “This feels like the flare I had two years ago, only worse.” The nurse prepares a care plan to address both the acute exacerbation and the long-term management of the client’s MS. Drag each nursing intervention to the appropriate category of MS care.

A 35-year-old client with a 5-year history of relapsing-remitting multiple sclerosis (MS) is admitted to the medical unit with new-onset lower extremity weakness, difficulty walking, and blurred vision in the right eye. The client states, “This feels like the flare I had two years ago, only worse.” The nurse prepares a care plan to address both the acute exacerbation and the long-term management of the client’s MS. Drag each nursing intervention to the appropriate category of MS care.

A 56-year-old client with end-stage liver cirrhosis and known esophageal varices is admitted to the medical unit for worsening abdominal ascites. Thirty minutes after arrival, the client suddenly vomits a large volume of bright red blood (estimated 500 mL) and reports dizziness. Immediate assessment: BP: 88/54 mm Hg (baseline 118/72) HR: 128 bpm RR: 26, shallow SpO₂: 92% on room air Skin: pale, cool, diaphoretic Mental status: alert but anxious; drowsy on direct questioning Active bleeding from the mouth; blood pooling in the oropharynx Bloody emesis continues What is the nurse’s priority action?

A 64-year-old client with end-stage renal disease (ESRD) is admitted to the medical unit for community-acquired pneumonia. The client receives hemodialysis three times weekly via a left forearm AV fistula placed 9 months ago. Other relevant history: Right upper extremity: history of mastectomy with axillary lymph node dissection 3 years ago Bilateral lower extremities: chronic venous insufficiency, with intact skin A new graduate nurse is preparing to take the client’s vital signs and asks the charge nurse for guidance on blood pressure measurement. Which response by the charge nurse is most appropriate?

A 62-year-old client in the ICU is being treated for septic shock secondary to an intra-abdominal abscess. A central venous catheter and arterial line are in place. The client has received IV broad-spectrum antibiotics and is currently receiving a lactated Ringer’s infusion. Current assessment: BP: 86/52 mm Hg (MAP 63) HR: 118 bpm RR: 24 SpO₂: 95% on 2 L nasal cannula CVP: 1 mm Hg Urine output: 10 mL/hr over the past 2 hours Lactate: 3.8 mmol/L Skin: warm, dry, pink Mental status: restless but oriented Total fluids received so far: 750 mL of the prescribed 30 mL/kg CVC waveform: appropriate venous tracing; line aspirates easily and flushes without resistance Which action should the nurse implement first?

A 64-year-old client with end-stage renal disease (ESRD) is admitted to the medical unit for community-acquired pneumonia. The client receives hemodialysis three times weekly via a left forearm AV fistula placed 9 months ago. Other relevant history: Right upper extremity: history of mastectomy with axillary lymph node dissection 3 years ago Bilateral lower extremities: chronic venous insufficiency, with intact skin A new graduate nurse is preparing to take the client’s vital signs and asks the charge nurse for guidance on blood pressure measurement. Which response by the charge nurse is most appropriate?

A 52-year-old client is admitted to the medical unit with newly diagnosed diabetes insipidus (DI) following a recent traumatic brain injury. The client is alert but reports extreme thirst and has been voiding large volumes of pale, clear urine over the past 24 hours. Current assessment: BP: 96/58 mm Hg HR: 118 bpm RR: 20 Temp: 37.0°C (98.6°F) Mucous membranes: dry; skin tenting noted Urine output: 450 mL/hour for the last 4 hours (approximately 10 L/24 hr) Urine specific gravity: 1.002 (very dilute) Serum sodium: 152 mEq/L The client has not yet received desmopressin (DDAVP) or adequate fluid replacement. The nurse is monitoring for complications. Which complication should the nurse monitor for in this client with untreated diabetes insipidus?

A 52-year-old client is admitted to the medical unit with newly diagnosed diabetes insipidus (DI) following a recent traumatic brain injury. The client is alert but reports extreme thirst and has been voiding large volumes of pale, clear urine over the past 24 hours. Current assessment: BP: 96/58 mm Hg HR: 118 bpm RR: 20 Temp: 37.0°C (98.6°F) Mucous membranes: dry; skin tenting noted Urine output: 450 mL/hour for the last 4 hours (approximately 10 L/24 hr) Urine specific gravity: 1.002 (very dilute) Serum sodium: 152 mEq/L The client has not yet received desmopressin (DDAVP) or adequate fluid replacement. The nurse is monitoring for complications. Which complication should the nurse monitor for in this client with untreated diabetes insipidus?

Scenario: A nurse case manager is evaluating an 82-year-old client for transition to an independent living facility following hospitalization for community-acquired pneumonia. The client lives alone, has Medicare, and currently has no in-home support services. Instructions: For each assessment finding, click to indicate whether the finding Supports safe transition to independent living or Indicates need for a higher level of care.

A 65-year-old client weighing 75 kg is in septic shock secondary to community-acquired pneumonia. Initial treatment in the ED has included: Blood cultures × 2 IV broad-spectrum antibiotics (ceftriaxone + azithromycin) administered within 45 minutes of arrival 1.5 liters of 0.9% normal saline infused over the past hour (approximately 20 mL/kg of the prescribed 30 mL/kg total) Continuous cardiac monitoring and arterial line in place Current assessment after the 1.5 L bolus: BP: 82/40 mm Hg (MAP 54) HR: 124 bpm RR: 26, shallow SpO₂: 94% on 4 L nasal cannula CVP: 14 mm Hg (initial 4 mm Hg) Lactate: 4.4 mmol/L Urine output: 12 mL/hr Skin: warm, flushed, with mottling beginning over the knees Mental status: alert but anxious Which intervention should the nurse anticipate next?