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A nurse in an emergency department is caring for a client.

Exhibits

Which of the following information provided by the client indicates improvement? Select all that apply.

“I have gained 1.8 kg (4 lb) recently, and my BMI is 18.9.”

“My adult child prepares two meals per day for me.”

“My clothing is always clean and appropriate for the weather.”

“I receive three baths per week from a home care aide.”

“I frequently have toothaches and haven’t had dental care in a while.”

“I make eye contact and smile while speaking.”

Answer and Explanation

Correct Answer : A,B,E

The correct answer is choice a, b, e.

Choice A rationale: A recent weight gain of 1.8 kg (4 lb) with a BMI of 18.9 may indicate potential nutritional issues or underlying health problems that require further investigation.

Choice B rationale: Having an adult child prepare meals could suggest the client may have difficulties with meal preparation, possibly due to physical or cognitive limitations.

Choice C rationale: Clean and weather-appropriate clothing indicates the client is managing their personal hygiene and dressing appropriately, which does not typically prompt further assessment.

Choice D rationale: Receiving regular baths from a home care aide suggests the client has support for personal hygiene, which is generally a positive indicator and does not necessitate further assessment.

Choice E rationale: Frequent toothaches and lack of dental care can indicate poor oral health, which can have significant implications for overall health and nutrition, warranting a more detailed assessment.

Choice F rationale: Making eye contact and smiling while speaking generally indicates good social interaction skills and mental well-being, which does not typically prompt further assessment.

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Correct Answer is D

Explanation

The correct answer is Choice d. Positioning both hands on the grips with his elbows slightly flexed.

Choice A rationale:

Moving both crutches with the stronger leg forward first is incorrect for a three-point gait.This describes a two-point gait,which is used when a client can bear weight on both legs.In a three-point gait,the client bears weight on the unaffected leg and the crutches,not the stronger leg.
This action would put excessive weight on the affected leg and could potentially compromise healing or cause further injury.

Choice B rationale:

Supporting his body weight while leaning on the axillary crutch pads is also incorrect.This can lead to nerve damage in the armpits and should be avoided.
The weight should be distributed through the hands and wrists,not the armpits.

Choice C rationale:

Stepping with his affected leg first when going up stairs is incorrect and potentially dangerous.The client should lead with the stronger leg when going up stairs to maintain balance and control.

Choice D rationale:

Positioning both hands on the grips with his elbows slightly flexed is the correct action for using crutches with a three-point gait.This allows for proper weight distribution,balance,and control of the crutches.
It also helps to prevent fatigue and strain in the arms and shoulders.

Key points to remember about the three-point gait:

Weight is borne on the unaffected leg and the crutches,not the affected leg.
The crutches and the unaffected leg move forward together,followed by the affected leg.
The client should look ahead,not down at their feet.
The client should take small,even steps.
The client should rest as needed.

A. Atrial fibrillation B. First-degree AV block C. Premature ventricular contraction D. Sinus bradycardia

Correct Answer is B

Explanation

The correct answer is B.

Choice A reason: Atrial fibrillation is characterized by a rapid, irregular heartbeat and an absence of distinct P waves on the ECG, which is not indicated by the information provided.

Choice B reason: First-degree AV block is indicated by a prolonged PR interval without affecting the overall heart rate, aligning with the client’s PR interval of 0.24 seconds.

Choice C reason: Premature ventricular contraction would show an abnormal QRS complex on the ECG, which is not mentioned in the scenario.

Choice D reason: Sinus bradycardia is defined by a heart rate less than 60 bpm, which does not apply here as the client’s heart rate is 69/min, within the normal range of 60-100 bpm.

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A nurse in an emergency department is caring for a client. Exhibits Which of the following information provided by the client indicates improvement? Select all that apply.

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A nurse in an emergency department is caring for a client.

Exhibits

Which of the following information provided by the client indicates improvement? Select all that apply.