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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Promoting trust involves actions that build a sense of trust and rapport between the nurse and the client. In this scenario, the nurse recognizes the client's basic need for food and responds to it promptly and compassionately. By interrupting the bath to address the client's hunger, the nurse demonstrates attentiveness and care, which helps establish trust between the nurse and the client.
Countertransference refers to the nurse's emotional reaction or response to the client, which may be based on the nurse's personal experiences or unresolved issues. It does not apply to the nurse's action of obtaining a meal for the client.
Veracity refers to truthfulness and honesty. While the nurse's action can be seen as honest and caring, it does not specifically relate to the concept of veracity.
Boundary crossing refers to a situation where the nurse exceeds the established professional boundaries with the client. In this scenario, the nurse's action of obtaining a meal for the client can be seen as a minor deviation from the routine care but is not considered a significant boundary crossing.
Correct Answer is B
Explanation
Informed consent is a process where the healthcare provider explains the risks, benefits, and alternatives of a proposed procedure or treatment to the client. The client then demonstrates their understanding of this information and voluntarily agrees to undergo the procedure or treatment.
A. "I will have a large scar on my stomach after this procedure". This is incorrect for a vaginal hysterectomy, which does not involve an abdominal incision.
B. 'I am thankful I am done having children." This statement reflects an understanding of a key consequence of a hysterectomy, which is the removal of the uterus and the resulting inability to have children. This indicates that the client is aware of and accepts the major impact of the surgery on their reproductive capabilities.
C."I should expect my periods to resume in 1 month.": This is incorrect because the removal of the uterus means the client will no longer have menstrual periods.
D."I will no longer need a regular gynecological examination.": This is incorrect because regular gynecological examinations are still necessary to monitor overall reproductive health and screen for other conditions.
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