ATI Nur258 Med Surg 2 Final Exam | Nurselytic

Extract:

Medical History
Client admitted with report of polyuria and polydipsia.
Notable muscle twitching of upper extremities.
Past medical history: Varicella as a child. No other health issues.
Current medications: Occasional ibuprofen for pain.
Family history: Father had history of nephrogenic diabetes insipidus.

Physical Examination
Alert and oriented to person, place, and time.
Client states that they have had difficulty concentrating lately and are irritable.
Client reports occasional dizziness.
Skin is warm, dry, and scaly.
Mucous membranes dry and pink.
Lungs clear to auscultation bilaterally.
Abdomen soft, nondistended with active bowel sounds x 4.
Denies nausea, vomiting, or diarrhea.
Peripheral pulses 1+
Twitching noted in upper extremities, client states they have had twitching "for some time."

Nurses' Notes
0845:
Needed assistance to the bathroom, reports dizziness.
Urine output 1,500 mL.
Assisted client to bed.
Vitals taken.

Vital Signs
0800:
Temperature 37.4° C (99.4° F)
Heart rate 100/min
Respiratory rate 22/min
Blood pressure 108/78 mm Hg
SpO2 98% on room air
0900:
Temperature 37.4° C (99.4° F)
Heart rate 104/min
Respiratory rate 22/min
Blood pressure 96/70 mm Hg

Diagnostic Results
Basic metabolic profile
Sodium 157 mEq/L (nl. 136-145 mEq/L)
Potassium 3.49 mEq/L (nl. 3.5-5 mEq/L)
Chloride 102 mEq/L (nl. 98-106 mEq/L)
Magnesium 1.8 mEq/L (nl. 1.8-2.6 mEq/L)
Total calcium 9.7 mg/dL (nl. 8.8-10.4 mg/dL)
Complete blood count (CBC) with differential
Total white blood cell (WBC) count 6,500/mm3 (nl. 5,000-10,000/mm3)
Neutrophils 60% (55% to 70%)
Lymphocytes 30% (20% to 40%)
Monocytes 5% (2% to 8%)
Eosinophils 2.5% (1% to 4%)
Basophils 0.7% (0.5% to 1%)
Hemoglobin 21 g/dL (Male: 14 to 18 g/dL; Female: 12 to 16 g/dL)
Hematocrit 55% (Male: 42% to 52%; Female: 37% to 47%)
RBCs 5.7 x 106µL (Male: 4.7 to 6.1 x 106µL; Female: 4.2 to 5.4 x 106µL

Extract: