A nurse is assisting in the care of a client in the emergency department (ED). Nurses' Notes 0205: Client brought to the ED by police after being found wandering on the street.
Client able to provide identity to police but not able to identify place or time.
Family notified.
Client confused and agitated.
Appearance is disheveled.
Mucous membranes dry.
Lungs clear and equal, heart rhythm regular.
During data collection, the client states, "Can you ask that person to leave my room?" Client is pointing to an empty chair.
Vital Signs 0200: Temperature 38.6°C (101.5°F), Heart rate 104/min, Respiratory rate 18/min, Blood pressure 158/96 mm Hg, Oxygen saturation 98% on room air.
Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again.
Client confused and agitated.
Appearance is disheveled.
Mucous membranes dry
During data collection, the client states, "Can you ask that person to leave my room?" Client is pointing to an empty chair.
Temperature 38.6°C (101.5°F)
Blood pressure 158/96 mm Hg
Heart rate 104/min
Respiratory rate 18/min
Oxygen saturation 98% on room air.
The Correct Answer is ["A","B","C","D","E","F"]
The findings that require immediate follow-up are:
- Client confused and agitated: This could indicate a neurological issue or other serious condition that needs immediate attention.
- Appearance is disheveled: This could suggest neglect or other issues that need to be addressed.
- Mucous membranes dry: This could indicate dehydration which can be serious if not addressed promptly.
- Client states “Can you ask that person to leave my room?” Client is pointing to an empty chair: This could indicate hallucinations or other mental health concerns that need immediate attention.
- Temperature 38.6°C (101.5°F): This is a fever and could indicate an infection or other medical condition that needs immediate attention.
- Blood pressure 158/96 mm Hg: This is high and could indicate hypertension or other cardiovascular issues that need immediate attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
A school-age child wanting to go to summer camp is not at a higher risk for physical abuse.
Choice B rationale:
A toddler with cystic fibrosis is at a higher risk for physical abuse due to the stress and demands of caring for a child with a chronic illness.
Choice C rationale:
An adolescent preparing to leave home for college is not at a higher risk for physical abuse.
Choice D rationale:
A preschooler who is reluctant to share is not at a higher risk for physical abuse.
Correct Answer is C
Explanation
Choice A rationale:
Phenobarbital is a barbiturate, not typically used in the treatment of opioid use disorder.
Choice B rationale:
Diazepam is a benzodiazepine, not typically used in the treatment of opioid use disorder.
Choice C rationale:
Buprenorphine is a medication approved for the treatment of opioid use disorder. It helps to reduce cravings and withdrawal symptoms.
Choice D rationale:
Chlordiazepoxide is a benzodiazepine, not typically used in the treatment of opioid use disorder.
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