A nurse in a clinic is caring for a client who has gastroenteritis. The nurse compares the client's condition from two days ago and today. Which of the following changes should the nurse report to the provider?
The client is confused and appears weak.
The client's oral mucosa is dry and tongue is furrowed.
The client's lungs are clear bilaterally.
The client's abdomen is soft and nontender.
The Correct Answer is A
Choice A reason: Confusion and weakness are signs of dehydration and electrolyte imbalance, which can result from vomiting and diarrhea. These are serious complications that can affect the client's mental status, blood pressure, heart rate, and kidney function. The nurse should report these changes to the provider and monitor the client's vital signs and fluid status.
Choice B reason: Dry oral mucosa and furrowed tongue are also signs of dehydration, but they are less severe than confusion and weakness. The nurse should report these changes to the provider as well, but they are not the most urgent ones.
Choice C reason: Clear lungs bilaterally are a normal finding and do not indicate any change in the client's condition. The nurse should document this finding, but it does not require reporting to the provider.
Choice D reason: A soft and non-tender abdomen is a normal finding and does not indicate any change in the client's condition. The nurse should document this finding, but it does not require reporting to the provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Ground beef is high in saturated fat and cholesterol, which can increase the risk of gallstones. A client with cholecystitis should avoid fatty, greasy, or fried foods; meats; and cheeses.
Choice B reason: Graham crackers are low in fat and high in fiber, which can help prevent gallstones. A client with cholecystitis should eat more foods that are high in fiber, such as fruits, vegetables, beans, and whole grains.
Choice C reason: Blueberry muffins may contain butter, eggs, or milk, which are sources of saturated fat and cholesterol. A client with cholecystitis should eat fewer refined carbohydrates and less sugar.
Choice D reason: 2% milk is a dairy product that contains saturated fat and cholesterol. A client with cholecystitis should eat healthy fats, like fish oil and olive oil, to help the gallbladder contract and empty on a regular basis.
Correct Answer is A
Explanation
Choice A reason: Confusion and weakness are signs of dehydration and electrolyte imbalance, which can result from vomiting and diarrhea. These are serious complications that can affect the client's mental status, blood pressure, heart rate, and kidney function. The nurse should report these findings to the provider and monitor the client's vital signs and fluid status.
Choice B reason: Dry oral mucosa and furrowed tongue are also signs of dehydration, but they are less severe than confusion and weakness. The nurse should report these findings to the provider as well, but they are not the most urgent ones.
Choice C reason: A temperature of 37.4° C (99.3° F) is slightly elevated, but not indicative of a fever or infection. The nurse should document this finding, but it does not require immediate follow-up.
Choice D reason: A blood pressure of 90/58 mm Hg is low, but not hypotensive. The nurse should document this finding, but it does not require immediate follow-up.
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