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A nurse is admitting a client who reports tightness in their chest that radiates to left arm.

Exhibits

The nurse is reviewing the client's medical record. Select the four findings that require immediate follow-up.

Blood glucose level

Bowel sounds

Blood pressure

Pain level

Electrocardiogram findings

Lung sounds

Troponin T level

Answer and Explanation

Correct Answer : C,D,E,G

A)   The client’s blood glucose in this scenario is within the normal range.
B)   The bowel sounds in this scenario are present in all the 4 quadrants which is normal.
C)   The client's blood pressure is elevated at 164/80 mm Hg. Hypertension can exacerbate cardiac ischemia and increase the risk of complications. Therefore, monitoring and potential management of blood pressure are warranted.
D)   The client's blood pressure is elevated at 164/80 mm Hg. Hypertension can exacerbate cardiac ischemia and increase the risk of complications. Therefore, monitoring and potential management of blood pressure are warranted.
E)   The client's blood pressure is elevated at 164/80 mm Hg. Hypertension can exacerbate cardiac ischemia and increase the risk of complications. Therefore, monitoring and potential management of blood pressure are warranted.
F)   The lungs are clear on auscultation of all the lobes which is normal.

G) The client's blood pressure is elevated at 164/80 mm Hg. Hypertension can exacerbate cardiac ischemia and increase the risk of complications. Therefore, monitoring and potential management of blood pressure are warranted.

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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"A"},"F":{"answers":"C"}}

Explanation

A) Coughing is not directly related to the client's condition as described in the scenario.
B) Keeping the client's head in a midline position is anticipated to maintain an open airway and prevent further complications, particularly after a cerebrovascular accident.
C) Elevating the head of the bed is anticipated as it can help improve respiratory function and reduce intracranial pressure, which is beneficial given the client's history of cerebrovascular accident and current restlessness and agitation.
D) Assisting the client to the bathroom is contraindicated due to the client's current unresponsiveness and risk of falls; a bedpan or catheter may be more appropriate.
E) Initiating seizure precautions is anticipated because the client's Glasgow Coma Scale score indicates a decreased level of consciousness, which could predispose them to seizures, especially with a history of cerebrovascular accident.
F) Decreasing oxygen to 1.5 L/min via nasal cannula is contraindicated given the client's decreased oxygen saturation levels; instead, the nurse should anticipate the need to maintain or increase oxygen to ensure adequate tissue perfusion.

A. Obtain a board that uses colored pictures as communication. B. Request an interpreter during the initial assessment. C. Familiarize themselves with commonly used signed language. D. Ask a family member to be present during the admission.

Correct Answer is B

Explanation

A) Using a communication board with colored pictures might not effectively facilitate communication for someone who primarily uses sign language.
B) Requesting an interpreter during the initial assessment ensures effective communication between the nurse and the client.
C) Familiarizing themselves with commonly used signed language may help the nurse in the long term but may not be feasible or effective during the immediate admission process.

D) Asking a family member to be present during the admission may help but may not provide the necessary communication support for effective assessment and care.

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A nurse is admitting a client who reports tightness in their chest that radiates to left arm. Exhibits The nurse is reviewing the client's medical record. Select the four findings that require immediate follow-up.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"A"},"F":{"answers":"C"}}

Explanation

A client who is deaf and communicates using sign language is being admitted by a nurse who does not know sign language. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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A nurse is admitting a client who reports tightness in their chest that radiates to left arm.

Exhibits

The nurse is reviewing the client's medical record. Select the four findings that require immediate follow-up.