A nurse is assisting in the care of a client who presents to the emergency department.
A nurse is reviewing the client's medical record. Which of the following findings indicate the need for further evaluation?
Heart rate
Blood pressure
Temperature
Respiratory complaint
Oxygen saturation
Weight loss
Sputum characteristics
Travel history
Correct Answer : C,D,F,G,H
A. a. Heart rate (98/min): A heart rate of 98/min is within the normal range for adults (60-100 bpm). This does not indicate an immediate need for further evaluation based on the provided data.
B. Blood pressure (112/88 mmHg): The blood pressure reading is within normal limits. This does not suggest an immediate concern.
C. Temperature: The client reports a low-grade fever (38.1°C or 100.5°F), which suggests an ongoing infection or inflammatory process. Further evaluation is necessary.
D. Respiratory complaint: A productive cough with blood-tinged sputum, especially in combination with symptoms such as fatigue, night sweats, and weight loss, is concerning and warrants further evaluation for possible serious conditions such as tuberculosis (TB) or other respiratory infections.
e. Oxygen saturation (98% on room air): The oxygen saturation is normal. This finding does not indicate an immediate need for further evaluation.
F.Weight loss: The client reports a significant weight loss of 26 kg (5 lbs) over the past week. Unintentional weight loss can be a concerning symptom and may indicate an underlying medical condition that requires further investigation.
G.Sputum characteristics: Blood-tinged sputum, especially with other symptoms like cough, fever, and night sweats, can be indicative of serious conditions such as TB or other respiratory infections and needs further evaluation.
H.Travel history: Recent travel to a region where certain infectious diseases are prevalent (such as TB) is a critical factor that requires further evaluation in the context of the client's symptoms.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Explanation:
Displacement is a defense mechanism in which an individual redirect their emotions or impulses from their original target to a less threatening or safer target. In this scenario, the client yells at the nurse when medication changes are prescribed by the provider. The client may be feeling angry or frustrated about the medication changes but is unable to express those emotions directly towards the provider. Instead, the client displaces those feelings onto the nurse, who may be seen as a safer or more accessible target. The yelling behavior directed at the nurse is a way for the client to release and express their emotions indirectly.
Let's briefly discuss the other defense mechanisms mentioned:
A- Conversion: Conversion involves the expression of psychological distress or conflict through physical symptoms or ailments. It is not applicable in this scenario since the client's behavior does not involve physical symptoms.
B- Splitting: Splitting is a defense mechanism characterized by a black-and-white thinking pattern, where individuals perceive others or situations as all good or all bad. It does not directly apply in this scenario as the client's behavior is not indicative of splitting.
D- Sublimation: Sublimation is a defense mechanism in which an individual channel their unacceptable or potentially harmful impulses into socially acceptable outlets, such as creative or productive activities. It is not evident in this scenario as the client's behavior does not involve transforming the emotions into a more positive or socially acceptable form.
Correct Answer is B
Explanation
Explanation
B. Instruct the client to change positions frequently
Encouraging the client to move around, walk, change positions during labour can help relieve discomfort, promote optimal fetal positioning positions, or use a birthing ball can help alleviate pelvic pain and potentially facilitate the progress of labour.
Applying fundal pressure during contractions in (option A) is not necessary during the latent stage of labour. Fundal pressure is typically used in the active stage of labour to assist with the descent and positioning of the baby's head.
Telling the client to push during contractions in (option C) is not appropriate during the latent stage of labour. Pushing is typically reserved for the second stage of labour when the cervix is fully dilated.
Encouraging the client to soak in a hot bath in (option D) is not recommended during labour, particularly in the hospital setting. Immersion in hot water (e.g., a hot bath) can increase the risk of infection and is generally not recommended until after the birth of the baby
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