A nurse is assisting in the care of a newly admitted client.
Which of the following findings should the nurse report immediately to the provider? Select all that apply
Temperature
Blood pressure
Pain
Urine output
Heart rate
Respiratory status
Sodium level
Mental confusion
Serum amylase level
Cold, clammy skin
Correct Answer : A,B,E,F,H,J
A. Temperature: The client’s temperature increased from 37.2°C (99°F) to 38.9°C (102°F), indicating a possible infection or systemic inflammatory response. Fever in acute pancreatitis can suggest worsening inflammation, infection, or sepsis and should be reported immediately.
B. Blood pressure: The client's blood pressure dropped from 126/78 mmHg to 92/48 mmHg, indicating hypotension, which could be due to fluid shifts, systemic inflammation, or early shock. Immediate intervention is necessary to prevent hemodynamic instability.
C. Pain: While severe pain (rated 10/10) is expected in acute pancreatitis, it is not the most urgent concern requiring immediate reporting compared to hemodynamic instability and respiratory distress.
D. Urine output: The current urine output is not critically low (50-60 mL/hr), but continued monitoring is necessary. However, it is not an immediate life-threatening concern requiring urgent reporting.
E. Heart rate: The client’s heart rate increased from 90/min to 132/min, which is a significant tachycardia. This suggests compensatory shock, fluid loss, or worsening systemic inflammation and requires immediate provider notification.
F. Respiratory status: The respiratory rate increased from 18/min to 32/min, and oxygen saturation dropped to 88% on 3 L/min O₂. This suggests respiratory compromise, possibly due to worsening systemic inflammation, pleural effusion, or acute respiratory distress syndrome (ARDS).
G. Sodium level: The sodium level remains within the normal range (142 mEq/L; normal: 136-145 mEq/L), so it does not require immediate reporting.
H. Mental confusion: The client, who was alert on Day 1, is now disoriented. This change in mental status can indicate worsening systemic inflammation, hypoxia, or impending shock, requiring urgent intervention.
I. Serum amylase level: While elevated (498 units/L), this is expected in pancreatitis and does not require immediate notification unless there is a sudden drastic change.
J. Cold, clammy skin: This is a sign of poor perfusion and possible shock. It indicates worsening hemodynamic instability and requires immediate intervention.
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Related Questions
Correct Answer is D
Explanation
A) "Carry your newborn back to the nursery in your arm when you need to rest.": This statement is not recommended. Carrying the newborn around, especially when the mother is feeling fatigued or unwell, can increase the risk of accidental drops or falls. Newborns should be placed in a bassinet or crib, and if the mother needs to rest, she should use assistance to ensure the baby is safely secured in their sleeping area.
B) "Request that the nurses show their nursing license prior to removing your newborn from the room.": While it’s important to ensure that the staff is authorized to care for the newborn, it may not be practical or necessary to request to see a nursing license every time someone comes to take the baby. Instead, the hospital usually has strict protocols in place for identifying staff, and it is better to rely on the facility's established security measures to verify authorized personnel.
C) "Leave your newborn in the bassinet in your room while you use the bathroom.": This statement is not ideal because, while it may seem safer to leave the baby in the bassinet, the nurse should encourage the mother to keep the baby nearby or alert a nurse to assist if needed. It is safer to have the baby in a secure place or ask for help to avoid the risk of falls or accidents while the mother is not attending to the baby.
D) "Alert the staff if any of your newborn's identification bands are missing.": This is the correct and most important instruction. Newborns should always be closely monitored to prevent abductions or mix-ups, and the identification bands are critical for verifying the baby's identity. If any identification bands are missing, it is essential to notify the staff immediately to ensure the newborn’s safety and prevent any potential security risks.
Correct Answer is B
Explanation
A) Increase in concentration: Chlorpromazine is an antipsychotic medication used to manage symptoms of schizophrenia and other psychotic disorders. While it may have some effects on cognition, an increase in concentration is not the primary therapeutic effect of chlorpromazine.
B) Decrease in delusions: Chlorpromazine is effective in reducing symptoms of psychosis, such as delusions and hallucinations, which are common in conditions like schizophrenia. A decrease in delusions is a direct indicator that the medication is having its intended therapeutic effect.
C) Increase in alertness: Chlorpromazine can cause sedation and drowsiness as side effects, particularly during the initial stages of treatment. An increase in alertness would not be a typical therapeutic outcome, and it may even suggest a side effect like overstimulation or anxiety rather than the intended effect.
D) Decrease in anxiety: While chlorpromazine may have some calming effects, it is primarily used to treat symptoms of psychosis, not anxiety disorders. A decrease in anxiety is not the main therapeutic effect of chlorpromazine. Other medications, such as benzodiazepines, are typically used for anxiety management.
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