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A nurse is assisting in the care of a client who presents to the emergency department.

Exhibits

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

Answer and Explanation

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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Correct Answer is A

Explanation

A. I have to take this medication on an empty stomach: Pantoprazole, a proton pump inhibitor (PPI), should be taken on an empty stomach, typically 30 minutes before a meal, for optimal absorption and effectiveness in reducing stomach acid.

B. I will need to remain upright for 1 hour after taking the medication: While remaining upright after meals is recommended for individuals with GERD to prevent reflux, this is not a specific instruction related to pantoprazole. The primary concern for pantoprazole is taking it before meals.

C. I should expect to have diarrhea while taking this medication: Diarrhea is not a common side effect of pantoprazole. The most common side effects include headache, nausea, or gastrointestinal disturbances, but diarrhea is not typically expected.

D. I can take antacids at the same time as this medication: Antacids should generally not be taken at the same time as pantoprazole. Taking antacids can interfere with the absorption of pantoprazole and reduce its effectiveness. It's usually advised to space them out by at least 2 hours.

A. "Why don't you want to learn how to give yourself your medication?" B. "You will suffer serious health issues if you don't take your medication." C. "I'd like to hear your thoughts about giving yourself this medication." D. "Have you considered how your decision to refuse medication will affect your family?"

Correct Answer is C

Explanation

This response allows the nurse to express genuine interest in the client's perspective and opens up a dialogue to understand the client's concerns or reasons for refusing to learn how to self-administer insulin. It provides an opportunity for the client to express their fears, doubts, or any barriers they may have. By actively listening to the client, the nurse can better address their concerns and provide appropriate education and support tailored to their individual needs.

The other options may come across as confrontational, judgmental, or unhelpful in establishing a therapeutic relationship with the client. It is important for the nurse to approach the situation with empathy, respect, and a non-judgmental attitude to foster effective communication and promote the client's engagement in their own care.

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A nurse is assisting in the care of a client who presents to the emergency department. Exhibits A nurse is reviewing the client's medical record. Which of the following findings indicate the need for further evaluation?

Nursing Test Bank

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A nurse is assisting in the care of a client who presents to the emergency department.

Exhibits

A nurse is reviewing the client's medical record. Which of the following findings indicate the need for further evaluation?