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A nurse is assisting in the care of a newly admitted client.

Exhibits

Which of the following findings should the nurse report immediately to the provider?

Select all that apply.

Heart rate

Pain

Cold, clammy skin

Mental confusion

Respiratory status

Blood pressure

Urine output

Temperature

Sodium level

Answer and Explanation

Correct Answer : A,C,D,F,G,H

A. The heart rate increased from 90/min on Day 1 to 110/min on Day 2, indicating tachycardia. This can signify an underlying issue, such as hypovolemia or sepsis, especially given the other concerning findings.

B. While the pain level increased from 3/10 to 6/10, pain itself is subjective and should be monitored closely. It may require adjustment in pain management but is not immediately life-threatening compared to other findings.

D. The client's confusion and slow response can indicate a change in neurological status, possibly related to electrolyte imbalances, dehydration, or infection. This is a significant finding that requires immediate attention.

C. The client's skin changed from warm and dry to pale, cool, and clammy, suggesting possible shock or hypoperfusion. This is a critical sign that needs to be communicated to the provider.

E. The respiratory rate increased from 18/min to 22/min, indicating mild respiratory distress. While concerning, it does not represent an acute emergency compared to other findings and should be monitored.

F. The blood pressure dropped from 126/78 mm Hg on Day 1 to 80/60 mm Hg on Day 2, indicating possible hypotension. This change could signify worsening clinical status, potentially indicating shock or significant fluid loss.

G. The urine output decreased significantly from 400 mL over 8 hours to 100 mL over 6 hours, indicating possible acute kidney injury or dehydration.

H. The client’s temperature has increased from 37.2°C (99°F) to 38.4°C (101.1°F), indicating a possible infection or inflammatory response.

I. The sodium level remains within normal limits (144 mEq/L) and does not show significant changes. Therefore, it does not require immediate reporting.

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Correct Answer is ["A","B","C","E","F","G","H"]

Explanation

A.Caffeine can exacerbate symptoms of mania by increasing restlessness and irritability. Avoiding caffeine can help in managing these symptoms.

B.Lithium is a common medication used to manage manic episodes in bipolar disorder. Monitoring lithium levels is crucial to ensure the client's safety and therapeutic effectiveness.

C.Clients experiencing mania may have difficulty focusing and completing tasks, including personal hygiene. Step-by-step reminders can help the client maintain proper hygiene.

D.While social interaction can be beneficial, clients in a manic state may become overstimulated or disruptive in group settings. Individual activities are often more appropriate until the mania is better controlled.

E.Clients in a manic state may be too restless to sit down for meals. Offering finger foods allows them to eat while on the go, helping to maintain adequate nutrition.

F.Clients with mania may exhibit aggressive behaviors. Redirecting these behaviors to safer or more appropriate outlets is important for the safety of the client and others.

G.The client's vital signs indicate an increase in heart rate and blood pressure, which are important to monitor closely as they can be affected by the heightened physical activity and agitation associated with mania.

H.Lithium can cause fluid retention and weight gain. Daily weight monitoring helps detect sudden increases that may indicate fluid imbalance or early signs of lithium toxicity. It also assists in managing and adjusting treatment as needed to prevent complications.

A. Don gloves prior to assisting the client with brushing their teeth. B. Place the client in a room with high-efficiency particulate air (HEPA. filter. C. Ensure that the negative air pressure is active for the client's room. D. Have the client wear a mask when they are out of their room.

Correct Answer is A

Explanation

A. Correct. MRSA is spread through direct contact with infected skin or surfaces. Wearing gloves when providing care to a client with MRSA helps prevent the spread of the bacteria.
B. Incorrect. The use of HEPA filters and negative air pressure is typically reserved for airborne infections such as tuberculosis. MRSA is primarily spread through direct contact.
C. Incorrect. Negative air pressure is not typically necessary for preventing the spread of MRSA, which is primarily spread through contact.
D. Incorrect. Wearing a mask when out of the room is not a standard precaution for MRSA, which is not primarily transmitted through the airborne route.

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A nurse is assisting in the care of a newly admitted client. Exhibits Which of the following findings should the nurse report immediately to the provider? Select all that apply.

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A nurse is assisting in the care of a newly admitted client.

Exhibits

Which of the following findings should the nurse report immediately to the provider?

Select all that apply.