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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 D

Explanation

Including the client's physical assessment findings will provide important information to the physical therapist regarding the client's current condition, limitations, and areas that require rehabilitation or therapy.

While family medical history is important for comprehensive healthcare, it may not be specifically relevant to the referral for a physical therapist unless there is a specific genetic or familial condition that could impact the therapy or rehabilitation process.

Medical health insurance claims are primarily related to billing and reimbursement and may not provide pertinent information to the physical therapist unless there are specific coverage limitations or requirements that need to be considered.

While medication history is important for overall healthcare management, it may not be directly relevant to the referral for a physical therapist unless there are specific medications that could affect the therapy or rehabilitation process (e.g., medications that may cause drowsiness or affect balance).

A. Hypotension B. Constipation C. Slurred speech D. New onset of hearing loss

Correct Answer is D

Explanation

Gentamicin is an aminoglycoside antibiotic that is known to have potential ototoxicity, which means it can cause damage to the inner ear and result in hearing loss. It is important for the nurse to monitor the client's hearing during gentamicin therapy and report any changes or symptoms of hearing loss promptly. Other adverse effects of gentamicin may include nephrotoxicity (kidney damage), so monitoring renal function is also essential.

Hypotension, constipation, and slurred speech are not typically associated with gentamicin use. However, it is important for the nurse to monitor the client for any adverse effects and report any concerning symptoms to the healthcare provider.

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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?