A nurse in a walk-in clinic is caring for a client.
Which of the following six findings should the nurse report to the provider? Select the 6 findings that require immediate follow-up.
1300:
- Temperature 39.1° C (102.4° F)
- Heart rate 115/min
- Respiratory rate 30/min
- Blood pressure 99/58 mm Hg
- Oxygen saturation 93% on room air
1330:
- Temperature 39.2° C (102.5° F)
- Heart rate 118/min
- Respiratory rate 28/min
- Blood pressure 91/52 mm Hg
- Oxygen saturation 95% on 2 L/min nasal cannula
- Heart rate
- Skin turgor
- Temperature
- Heart sounds
- Blood pressure
- COVID test results
- Orientation
- Lung sounds
Temperature 39.1° C (102.4° F)
Blood pressure
Skin turgor
Temperature 39.2° C (102.5° F)
COVID test results
The Correct Answer is ["A","D"]
Temperature 39.1° C (102.4° F), Temperature 39.2° C (102.5° F)
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
False imprisonment is the correct answer because it occurs when a person intentionally restricts the freedom of movement of another person without proper consent or legal justification. In this scenario, the AP is threatening to place the client in restraints against their will if they do not comply with bed rest. This action is a violation of the client's rights and constitutes false imprisonment.
Choice B reason:
Defamation of character is incorrect: Defamation involves making false statements about someone that harm their reputation. It doesn't apply to this scenario.
Choice C reason:
Battery is incorrect: Battery involves intentional harmful or offensive physical contact with another person without their consent. There is no indication of physical contact in this situation.
Choice D reason:
Assault is incorrect. Assault refers to the intentional threat or act that causes fear of imminent harmful or offensive contact. While there is a threat implied in this scenario, the threat is of false imprisonment rather than physical harm, making false imprisonment a more accurate description of the tort.
Correct Answer is C
Explanation
Choice A reason:
A registered dietitian is not appropriate as he or she can provide nutritional assessment and guidance to ensure the client's dietary needs are met.
Choice B reason:
A speech-language pathologist is not appropriate because it is crucial for addressing communication and swallowing difficulties that can arise from a stroke.
Choice C reason:
Occupational therapy is the right choice. Clients who have had a stroke often experience difficulties with activities of daily living (ADLs) due to the physical and cognitive changes that can result from the stroke. Occupational therapists are specialized in helping individuals regain or develop the skills needed to perform daily activities and tasks. They can assist stroke survivors in regaining independence in activities such as dressing, grooming, bathing, and feeding.
Choice D reason:
A physical therapist can assist with mobility and improving physical functioning, but since the question specifically mentions assistance with morning ADLs, the occupational therapist is the most appropriate choice.
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