Flare-Ups
A 70-year-old client reports knee pain that worsens with activity, improves with rest, and morning stiffness lasting about 15 minutes. Physical exam reveals crepitus and joint-space narrowing on X-ray. These findings are characteristic of this chronic joint disorder.
What is osteoarthritis?
Rationale:
OA is degenerative, non-inflammatory, causes pain with use, and has short-duration morning stiffness with crepitus and joint-space narrowing.
A client with a newly applied forearm cast reports tingling in the fingers. The nurse assesses capillary refill, movement, sensation, skin temperature, and pulses distal to the cast. These measurements together constitute this essential post-cast assessment.
What are neurovascular checks?
Rationale:
Neurovascular checks evaluate circulation and nerve function distal to an immobilized limb and help detect early complications.
A client with asthma uses their rescue inhaler during an acute episode and reports feeling shaky with a slightly increased heart rate afterward. The nurse explains these findings are an expected short-term effect of this commonly used medication for sudden bronchospasm.
What is a short-acting beta agonist?
Rationale:
SABAs (like albuterol) stimulate beta receptors, causing temporary tachycardia and tremors.
A client with coronary artery disease is reviewing foods to reduce their risk of further plaque buildup. They report switching from fried foods to baked chicken, vegetables, fresh fruit, and whole grains. These choices reflect this type of heart-healthy diet pattern.
What is a low-saturated-fat diet?
Rationale:
CAD management emphasizes limiting saturated fats and choosing lean proteins, fruits, vegetables, and whole grains.
A postoperative client reports dizziness when standing. Assessment reveals blood pressure 92/56 mmHg, heart rate 118/min, and urine output of 20 mL/hr. These findings are consistent with this fluid imbalance.
What is hypovolemia?
Rationale:
Hypovolemia causes tachycardia, hypotension, and low urine output due to decreased circulating volume.
A client reports fatigue, brittle nails, and occasional dizziness. Labs show low hemoglobin and hematocrit, low ferritin, and elevated total iron-binding capacity (TIBC). These findings are consistent with this type of anemia.
What is iron-deficiency anemia?
Rationale:
Low ferritin and high TIBC reflect depleted iron stores, the hallmark of iron-deficiency anemia.
A client with major depressive disorder says, “I don’t see a point in living anymore,” avoids eye contact, and becomes tearful when asked to elaborate. When the nurse directly asks about access to means, the client reports having a loaded firearm at home and says, “I’ve thought about using it.” These findings require this immediate safety intervention.
What is initiating suicide precautions with constant observation?
Rationale:
Active suicidal thoughts plus access to a lethal means indicate an immediate risk of self-harm. The client requires continuous 1:1 observation and implementation of suicide precautions.
A client beginning treatment for depression asks why their mood has not improved during the first week, even though they feel slightly more alert. The nurse explains that mood improvement takes several weeks.
What are SSRIs?
Rationale:
SSRIs increase serotonin, but therapeutic mood effects take 2–4 weeks.
A client is scheduled for surgery and begins asking detailed questions about the risks and expected recovery. The nurse realizes the consent form should not be signed yet because this responsibility belongs to this person on the healthcare team.
Who is the surgeon?
Rationale:
Only the provider performing the procedure can obtain informed consent; the nurse only verifies understanding and witnesses the signature.
A client says, “I just feel overwhelmed and don’t know where to start.” Instead of offering advice or reassurance, the nurse encourages expression of feelings using this type of communication technique.
What is using open-ended questions?
Rationale:
Open-ended questions promote exploration of thoughts and improve assessment accuracy
A 40-year-old client presents with symmetric swelling in both hands, prolonged morning stiffness lasting more than an hour, fatigue, and low-grade fever. Labs show elevated ESR and positive rheumatoid factor. These findings indicate this autoimmune condition.
What is rheumatoid arthritis?
Rationale:
RA causes systemic inflammation, symmetric joint involvement, and prolonged stiffness with autoimmune markers.
A client with a full-leg cast reports severe, constant pain unrelieved by opioids, increasing pressure in the limb, and difficulty moving the toes. The toes are pale and cool with weak pulses. These findings indicate this emergent complication that must be reported immediately.
What is compartment syndrome?
Rationale:
Unrelieved pain plus neurovascular compromise signals compartment syndrome, a limb-threatening emergency requiring rapid intervention.
A client experiencing acute wheezing, shortness of breath, and chest tightness arrives at urgent care. The priority medication to relieve bronchospasm is this type of inhaler.
What is a short-acting beta-agonist?
Rationale:
SABAs provide rapid bronchodilation during acute asthma symptoms.
A client presents with chest pain and shortness of breath. Labs show elevated cardiac enzymes, but one value is especially high and remains elevated for several days, confirming myocardial injury. This biomarker is most specific for acute myocardial infarction.
What is troponin?
Rationale:
Troponin is highly specific to myocardial cell damage and is the gold standard for AMI diagnosis.
A 78-year-old client receiving hypotonic IV fluids becomes increasingly confused and complains of a worsening headache. Labs show a serum sodium level of 124 mEq/L. These findings indicate this electrolyte imbalance.
What is hyponatremia?
Rationale:
Neurological symptoms result from low sodium shifting water into brain cells; confusion and headache are early signs.
A client newly prescribed oral iron reports they plan to take it “with breakfast and a big glass of milk.” The nurse explains that iron is best absorbed when taken with this supplement instead.
What is vitamin C?
Rationale:
Vitamin C enhances iron absorption; dairy products decrease it.
A hospitalized client who stopped drinking 12 hours ago is restless, tremulous, diaphoretic, and has a pulse of 122/min. The nurse scores the client using the CIWA scale and prepares to administer this medication class, which is first-line for preventing seizures during withdrawal.
What are benzodiazepines?
Rationale:
Benzodiazepines (lorazepam, Ativan) are the primary treatment for alcohol withdrawal. A CIWA score helps guide dosing to prevent seizure activity and delirium tremens.
A client with Bipolar Disorder calls the clinic reporting new nausea, increasing tremors, and difficulty concentrating after several days of GI illness with poor fluid intake. The nurse recognizes these symptoms as concerning because dehydration can rapidly lead to this medication complication.
What is lithium toxicity?
Rationale:
Dehydration reduces lithium clearance, causing rising serum levels and early toxicity signs (GI upset, tremor, cognitive slowing).
A client arrives from the OR shivering, with a temperature of 96.8°F (36°C). The nurse initiates warm blankets and a warming device because anesthesia commonly causes this postoperative complication.
What is hypothermia?
Rationale:
Anesthesia depresses thermoregulation; warming interventions are standard PACU practice.
A client with a fixed delusion says, “The staff is poisoning my food.” The nurse calmly responds, “I can see this feels very real and frightening for you. Your meals are safe, and I’ll stay with you while you eat.”
This nursing response demonstrates an appropriate approach to supporting the client without reinforcing the delusion.
What is acknowledging feelings while presenting reality?
Rationale:
The nurse validates the emotion while clearly stating reality, which helps reduce fear without agreeing with or feeding into the delusion.
A client arrives with sudden severe pain, redness, and swelling in the great toe. They report eating steak and drinking several beers over the weekend. Serum uric acid is elevated. These findings indicate this acute inflammatory condition.
What is gout?
Rationale:
Gout flares are triggered by purine-rich foods and alcohol, particularly beer.
A post-operative client in the PACU is difficult to arouse, has shallow respirations, and an oxygen saturation of 86% on 2 L/min oxygen. These findings represent this priority PACU concern.
What is respiratory depression?
Rationale:
Airway and breathing are top PACU priorities. Sedation and anesthesia increase risk for respiratory depression, which must be addressed immediately.
A client with COPD becomes acutely short of breath during morning care. They are anxious, using accessory muscles, and have oxygen saturation of 89% on 2 L/min. Before adjusting oxygen, the nurse performs this immediate intervention to improve ventilation.
What is positioning the client upright and initiating pursed-lip breathing?
Rationale:
Upright positioning and pursed-lip breathing decrease air trapping and improve ventilation quickly.
A client taking captopril for hypertension develops swelling of the lips and difficulty swallowing. The nurse recognizes this as a serious adverse effect requiring immediate discontinuation of the medication.
What is angioedema?
Rationale:
ACE inhibitors (captopril, lisinopril) can cause life-threatening angioedema, requiring emergency intervention.
A client with prolonged vomiting presents with dry mucous membranes, tachycardia, and poor skin turgor. Labs show elevated serum sodium and increased hematocrit. These findings are consistent with this fluid deficit.
What is dehydration?
Rationale:
Hemoconcentration and elevated sodium occur when plasma volume is reduced.
A client reports numbness and tingling in their hands and feet and has a smooth, red, beefy tongue. Labs reveal a low B12 level. These findings are characteristic of this specific anemia.
What is pernicious anemia?
Rationale:
B12 deficiency causes neurologic symptoms and glossitis; these do not occur with iron deficiency alone.
A client is now 36 hours into alcohol withdrawal and suddenly becomes severely confused, has a low-grade fever, and reports seeing “bugs crawling on the walls.” These findings indicate this life-threatening complication.
What is delirium tremens?
Rationale:
DTs include severe confusion, hallucinations, fever, and autonomic instability; this is a medical emergency.
A client beginning long-term mood stabilizer therapy is scheduled for routine lab monitoring every few months. The nurse explains that this medication can gradually impair the body's ability to filter waste and regulate metabolism, making ongoing surveillance essential for safety.
What is lithium?
Rationale:
Lithium can cause chronic kidney impairment and hypothyroidism, so periodic renal and thyroid testing is required.
A client in the PACU is difficult to arouse and has shallow respirations of 10/min with an oxygen saturation of 90% on 2 L/min following IV opioids. The nurse first assesses this critical postoperative priority to prevent opioid-related respiratory compromise.
What is ventilation?
Rationale:
Airway and breathing are the top priorities after anesthesia and opioid use. Shallow respirations and decreased responsiveness indicate risk for hypoventilation and respiratory depression, requiring immediate assessment of ventilation.
A client arrives to the emergency department reporting a recent sexual assault. The nurse explains that a specially trained clinician will perform a detailed forensic exam, collect evidence, provide crisis support, and ensure the client’s consent is obtained at every step. This describes the role of this type of nurse.
What is a Sexual Assault Nurse Examiner (SANE)?
Rationale:
SANE nurses are specially trained to perform forensic evidence collection, provide trauma-informed care, ensure informed consent throughout the process, and support the client’s physical and emotional safety.
A client with chronic gout asks how to prevent future flare-ups. They state they plan to “cut back on alcohol and avoid organ meats.” The nurse reinforces that this specific dietary approach helps reduce uric acid production and inflammation.
What is following a low-purine diet?
Rationale:
Low-purine diets decrease uric acid formation and help prevent gout exacerbations.
A client 24 hours after surgery has a temperature of 101.8°F (38.8°C), productive cough, and diminished breath sounds at the bases. These findings suggest this likely postoperative complication.
What is atelectasis or pneumonia?
Rationale:
Early post-op fever plus respiratory symptoms commonly indicates atelectasis or pneumonia due to impaired ventilation and secretion clearance.
A client recovering from a total laryngectomy asks why they cannot breathe through their nose anymore. The nurse explains that after this surgery, airflow occurs only through this structure, which must be kept clean and protected.
What is the neck stoma?
Rationale:
Total laryngectomy removes the connection between the upper airway and lungs; breathing occurs solely through a permanent stoma.
A client newly prescribed atenolol reports dizziness when standing and a resting pulse of 54/min. The nurse explains that this medication slows heart rate and blood pressure because it belongs to this drug class used for managing hypertension.
What are beta blockers?
Rationale:
Beta blockers reduce heart rate and myocardial workload; bradycardia is a known effect.
A client taking a loop diuretic has a potassium level of 3.1 mEq/L and reports leg cramps and fatigue. The provider prescribes this additional medication to correct the low potassium level.
What is potassium replacement?
Rationale:
Loop diuretics increase renal potassium loss; supplementation restores normal levels.
A client presents with frequent infections, easy bruising, and fatigue. Labs show low red blood cells, low white blood cells, and low platelets. These findings indicate this hematologic disorder.
What is aplastic anemia?
Rationale:
Aplastic anemia involves bone marrow failure resulting in pancytopenia.
A veteran reports frequent nightmares, avoids crowded places, and becomes hyper-alert when hearing loud noises. These symptoms are consistent with this mental health condition.
What is post-traumatic stress disorder?
Rationale:
PTSD involves hypervigilance, avoidance, and re-experiencing traumatic events.
A client taking an SSRI reports sudden agitation, abdominal cramping, sweating, and muscle twitching after starting a new migraine medication. The nurse recognizes these symptoms as consistent with this potentially life-threatening reaction.
What is serotonin syndrome?
Rationale:
Combining serotonergic meds increases risk of hyperreflexia, agitation, GI upset, and autonomic instability.
A postoperative client asks why the nurse keeps reminding them to use the incentive spirometer. The nurse explains that this device helps prevent postoperative pneumonia by promoting this respiratory action.
What is lung expansion?
Rationale:
Incentive spirometry opens alveoli, reducing atelectasis and pneumonia risk
A client reports recent thoughts of suicide but denies having a specific plan. The nurse uses a structured tool that asks about the severity of thoughts, past attempts, intent, and behaviors such as rehearsing or preparing for self-harm. This tool helps determine the client’s level of suicide risk.
What is the Columbia–Suicide Severity Rating Scale (C-SSRS)?
Rationale:
The C-SSRS is a validated suicide-risk assessment tool that evaluates suicidal ideation, intent, plan, behaviors, and prior attempts. It helps clinicians determine the appropriate level of intervention and monitoring.
A client with systemic lupus erythematosus reports new sharp chest pain that worsens with deep breathing. Lung sounds are clear, and the client reports increased fatigue and joint pain over the past week. These findings suggest inflammation of this structure.
What is the pericardium or pleura?
Rationale:
SLE flares commonly cause pericarditis or pleuritis, producing sharp inspiratory chest pain without pulmonary consolidation.
A client is 12 hours post–tibial fracture with a splint in place. The client reports increasing pain, but assessment reveals NEW numbness, inability to dorsiflex the foot, slow capillary refill, and pale toes on the affected leg. These findings indicate this priority complication that requires immediate provider notification.
What is neurovascular compromise?
Rationale:
New loss of movement, sensation, and perfusion indicates impaired circulation or nerve function and must be treated as an emergency. Pain alone is not the highest priority—changes in neurovascular status are.
A client presents with chronic cough, night sweats, weight loss, and a positive sputum smear for acid-fast bacilli. The nurse immediately places the client in this type of isolation to prevent transmission.
What is airborne precautions?
Rationale:
TB spreads via airborne droplets; negative pressure and N95 use are required.
A client with heart failure taking furosemide and digoxin reports nausea and blurred vision. The apical pulse is 50/min and potassium level is 3.0 mEq/L. These findings indicate the client is experiencing this medication complication.
What is digoxin toxicity?
Rationale:
Bradycardia, visual changes, and GI symptoms indicate toxicity. Hypokalemia from diuretics increases the risk.
A client taking Furosemide reports muscle weakness and irregular heartbeats. ECG reveals flattened T waves. The nurse reviews labs and expects this electrolyte value to be decreased.
What is hypokalemia?
Rationale:
Flattened T waves, muscle weakness, and dysrhythmias indicate hypokalemia commonly caused by diuretics.
A client with sickle cell disease asks how to prevent future vaso-occlusive crises. The nurse explains that dehydration, infections, emotional stress, and high-altitude environments all increase the risk by promoting this change in red blood cell shape.
What is sickling of red blood cells?
Rationale:
Hypoxia, dehydration, and stress trigger RBC sickling, leading to painful crises.
A client pacing rapidly says, “I can’t calm down; something bad is going to happen,” and is unable to follow multi-step instructions. The nurse recognizes this level of anxiety and uses short, simple statements to promote safety.
What is severe anxiety?
Rationale:
Severe anxiety limits the ability to process information; communication must be simple and direct.
A provider considers prescribing bupropion for a client but first reviews the medical history for conditions such as traumatic brain injury, electrolyte disturbances, or eating disorders, which would increase the client's risk for this severe adverse effect.
What are seizures?
Rationale:
Bupropion lowers the seizure threshold; contraindicated with factors that worsen this risk.
A client is two days post–abdominal surgery and reports increasing abdominal distention, nausea, and absence of bowel sounds. They have not passed gas since surgery. These findings suggest this common postoperative complication.
What is a postoperative ileus?
Rationale:
Decreased bowel motility after anesthesia and opioid use causes ileus, presenting with distention and absent bowel sounds.
A client begins pacing rapidly and shouting at staff. The nurse remains calm, keeps distance, and states, “You’re very upset. I want to help, but I need you to lower your voice so we can talk safely.” This approach demonstrates this behavioral intervention.
What is setting clear, respectful limits?
Rationale:
Limit-setting provides structure, maintains safety, and models self-control without escalating conflict.
A newly diagnosed rheumatoid arthritis client asks whether they can “stop taking the steroid and DMARDs once the swelling goes down.” The nurse explains that stopping these medications abruptly increases the risk of flare and, in the case of steroids, this medical emergency.
What is adrenal insufficiency?
Rationale:
Steroids must be tapered to avoid adrenal crisis; DMARDs require continuous use to prevent disease progression.
A nurse admits a client from PACU who is drowsy but arousable after general anesthesia. The respiratory rate is 10/min, breath sounds are shallow, and oxygen saturation is 90% on 2 L/min. The nurse prioritizes this immediate assessment due to the effects of anesthesia.
What is ensuring adequate ventilation?
Rationale:
A low respiratory rate and shallow breathing after anesthesia place the client at risk for respiratory depression. Ventilation and airway patency are the highest priorities in the immediate post-anesthesia period.
A client suddenly develops severe respiratory distress, tracheal deviation to the opposite side, and decreasing blood pressure. These findings indicate this life-threatening complication requiring immediate intervention.
What is a tension pneumothorax?
Rationale:
Tracheal deviation, hypotension, and severe dyspnea indicate tension pneumothorax, a medical emergency requiring immediate decompression.
A client presents with shortness of breath when lying flat, crackles at the lung bases, and persistent fatigue. Their BNP is significantly elevated. These findings are consistent with this type of heart failure.
Response:
What is left-sided heart failure?
Rationale:
Left-sided HF causes pulmonary congestion, orthopnea, crackles, and elevated BNP.
Right-sided heart failure is more often associated with systemic findings such as peripheral edema, jugular venous distention, hepatomegaly, and weight gain.
A client with heart failure is receiving a blood transfusion and begins to develop increasing shortness of breath, crackles at the lung bases, and elevated blood pressure. These findings indicate this transfusion-related complication.
What is circulatory overload?
Rationale:
Blood products add volume; clients with HF are especially prone to transfusion-associated circulatory overload (TACO), which presents with dyspnea, crackles, and hypertension.
A client in acute sickle cell crisis reports severe pain and has an oxygen saturation of 88%. The nurse starts IV fluids and administers opioid analgesics as prescribed. These interventions help relieve symptoms because they improve this problem caused by sickled red blood cells.
What is impaired blood flow?
Rationale:
Sickled cells block blood vessels, causing poor perfusion and severe pain. IV fluids improve viscosity and opioids relieve pain from vaso-occlusion.
A client becomes increasingly agitated, pacing, clenching their fists, and making verbal threats. The nurse steps back, keeps an exit accessible, and signals for additional staff support. These actions demonstrate the nurse’s primary priority when behavior begins to escalate.
What is maintaining safety for the client and staff?
Rationale:
During escalating agitation, safety overrides all other interventions. The nurse first secures the environment, then proceeds with de-escalation techniques.
A client scheduled for electroconvulsive therapy expresses fear about “losing memories.” The nurse explains that a common cognitive effect of ECT is temporary difficulty recalling events close to the time of treatment. This effect is known as this.
What is short-term memory loss (retrograde amnesia)?
Rationale:
ECT most commonly causes short-term or retrograde amnesia for events occurring immediately before and after treatment; this effect is temporary.
A client using a PCA pump reports, “I’m getting really sleepy between doses, but I keep pressing the button when the pain returns.” The nurse reviews the vital signs, which are stable, and explains that excessive drowsiness while using PCA opioids may indicate this developing complication that requires close monitoring.
What is opioid oversedation?
Rationale:
Increasing drowsiness can indicate accumulating opioid effect. Teaching focuses on reporting early sedation and monitoring for respiratory decline.
A client experiencing severe psychosis refuses treatment but is acting in ways that place themselves at risk of harm. The nurse documents behaviors and collaborates with the provider to initiate this type of legal intervention for immediate safety.
What is a 72-hour involuntary (emergency) psychiatric hold?
Rationale:
A 72-hour involuntary hold allows providers to detain and evaluate a client who poses danger to themselves or others, or cannot meet basic needs due to mental illness. This order authorizes emergency treatment and assessment to stabilize the client and maintain safety.
A post-operative orthopedic client suddenly develops shortness of breath, sharp chest pain, and tachycardia. The nurse recognizes these findings as classic symptoms of this acute complication.
What is a pulmonary embolism?
Rationale:
Orthopedic surgery increases clot risk; sudden dyspnea and chest pain indicate PE.
A client prescribed spironolactone for heart failure states they plan to replace table salt with a potassium-containing salt substitute. The nurse teaches that doing so increases the risk of this electrolyte imbalance associated with potassium-sparing diuretics.
What is hyperkalemia?
Rationale:
Spironolactone retains potassium; salt substitutes may worsen hyperkalemia risk.
A client with multiple bruises in various stages of healing says they “fell again” but avoids eye contact and becomes tearful when their partner enters the room. The nurse recognizes these findings as indicators of this concern and must document objectively.
What is intimate partner violence?
Rationale:
Inconsistent injury explanations, fear of a partner, and patterned injuries are classic IPV indicators requiring mandated reporting protocols.
A client describes feeling “slowed down,” sleeping excessively, withdrawing from social activities, and struggling to make decisions for the past month. These symptoms reflect the functional impairment required to diagnose this condition.
What is major depressive disorder?
Rationale:
MDD requires a minimum of two weeks of impaired functioning with symptoms like anhedonia, cognitive slowing, and psychomotor changes.
A post-operative client becomes increasingly restless, reports a sense of “doom,” and their heart rate climbs from 92 to 128. Their blood pressure trends downward from 118/72 to 94/60, and the surgical dressing remains dry and intact. These clinical changes are most consistent with this early, life-threatening post-operative complication.
What is internal bleeding leading to early shock?
Rationale:
Tachycardia, hypotension, and restlessness are early indicators of hypovolemic shock. Internal bleeding may not appear externally, so dressing assessment alone cannot rule it out.