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A nurse in an outpatient mental health clinic is caring for a client. Select the 3 findings that require immediate follow-up.

A.

Weight

B.

Neuro status

C.

Auditory hallucinations

D.

Speech

E.

Restlessness

Answer and Explanation

Correct Answer : B,C,E

The correct answer is B, C, and E.

  • A. Weight is not a correct choice because it is not a vital sign and it does not indicate an acute change in the client's condition.
  • B. Neuro status is a correct choice because it reflects the client's level of consciousness, orientation, memory, and cognitive function. Any alteration in neuro status could indicate a serious problem such as infection, stroke, or medication toxicity.
  • C. Auditory hallucinations are a correct choice because they are a symptom of psychosis and could indicate a relapse or worsening of the client's mental illness. Auditory hallucinations could also impair the client's ability to cope, communicate, and function effectively.
  • D. Speech is not a correct choice because it is not a vital sign and it does not indicate an acute change in the client's condition. Speech could be affected by various factors such as mood, anxiety, or medication side effects.
  • E. Restlessness is a correct choice because it is a sign of agitation, anxiety, or discomfort. Restlessness could also indicate an underlying physical or psychological problem such as pain, infection, or psychosis.


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Related Questions

Correct Answer is ["B","C","E","F"]

Explanation

The four findings that require follow-up are B, C, E, and F.

Rationale:

  1. Blood pressure: A normal blood pressure for an adolescent is 110/70 mm Hg. The question does not provide the adolescent's blood pressure, so it cannot be determined if it requires followup or not.
  2. Capillary refill: A normal capillary refill time is less than 2 seconds. A prolonged capillary refill time indicates impaired blood flow to the extremity, which could be due to vascular injury, compartment syndrome, or shock.
  3. Pedal pulse: A normal pedal pulse is +2 or +3. A weak pedal pulse (+1) indicates reduced blood flow to the extremity, which could be due to vascular injury, compartment syndrome, or shock.
  4. Heart rate: A normal heart rate for an adolescent is 60 to 100 beats per minute. The question does not provide the adolescent's heart rate, so it cannot be determined if it requires follow-up or not.
  5. Skin temperature: A normal skin temperature is warm and dry. A cool skin temperature indicates reduced blood flow to the extremity, which could be due to vascular injury, compartment syndrome, or shock.
  6. Pain: A pain level of 10 on a scale of 0 to 10 indicates severe pain that needs to be managed with appropriate analgesics and nonpharmacological interventions.

Correct Answer is {"dropdown-group-1":"C"}

Explanation

Electrolyte imbalance in pregnant clients is often associated with conditions that lead to dehydration and nutritional deficiencies. In this scenario, the key indicators are persistent nausea and significant weight loss.

  • Persistent nausea can lead to reduced food and fluid intake. This condition, especially if prolonged, can cause dehydration and electrolyte imbalances due to the loss of essential minerals and nutrients that are not being replenished due to inadequate dietary intake.
  • Significant weight loss, particularly the amount described in the scenario (6.8 kg or 15 lb), is a clear sign of inadequate nutritional intake and can further exacerbate the risk of electrolyte imbalance. It indicates that the body is not receiving enough nutrients, which is crucial for maintaining electrolyte balance.

The other options, while related to diet and fluid intake, are more specific to the client's eating habits and do not directly point to the primary cause of potential electrolyte imbalance in the context of this scenario. Therefore, the most comprehensive and medically relevant choice is (A) Persistent nausea and significant weight loss.

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