Try Naxlex NCLEX-RN (Free-Trial)

A nurse is assisting in the care of an adolescent.

The nurse is reviewing the data collection findings.

Select the 5 findings the nurse should report to the provider.

Temperature

Sclera

Bowel sounds

Abdominal tenderness

Anorexia

Breath sounds

Heart rate

Skin

Answer and Explanation

Correct Answer : B,D,E,G,H

Temperature: A temperature of 37.5° C (99.5° F) is within the normal to slightly elevated range and is not high enough to be classified as fever. Therefore, it does not require immediate reporting unless accompanied by other signs of infection or systemic illness.
Sclera: Yellow-tinged sclera suggests jaundice, indicating possible liver dysfunction, which could be related to substance use or hepatitis. Jaundice is a significant clinical finding that requires immediate provider notification for further evaluation and management.
Bowel sounds: Hyperactive bowel sounds are a non-specific finding and can result from gastrointestinal irritation, substance use, or stress. Alone, they do not warrant urgent reporting unless accompanied by more serious signs like severe pain or vomiting.
Abdominal tenderness: Epigastric tenderness could suggest gastrointestinal complications such as hepatitis, pancreatitis, or gastritis, especially in the context of drug use. Abdominal pain on palpation is a concerning symptom that must be reported for further diagnostic workup.
Anorexia: Significant anorexia along with nausea, vomiting, and substance use points to potential systemic illness or gastrointestinal involvement. In adolescents, persistent anorexia is a warning sign that needs prompt evaluation to prevent nutritional deficiencies and worsening health.
Breath sounds: Clear breath sounds are a normal finding and do not require immediate provider notification. There are no respiratory concerns indicated by the lung assessment provided in the notes.
Heart rate: A heart rate of 103/min indicates mild tachycardia, which could be due to dehydration, substance use, or an underlying systemic condition. Tachycardia should be reported to assess if immediate interventions like fluid replacement are necessary.
Skin: Dry skin with poor turgor signals dehydration, a critical finding especially with the reported vomiting and drug use. Dehydration can rapidly worsen and must be addressed by the provider for fluid management and further care.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

A. Suggest the client exercise before going to bed: While exercise is beneficial for depression, vigorous activity before bedtime can interfere with sleep. It is generally better to recommend exercise earlier in the day to promote better rest and regulate mood.

B. Offer the client low-protein snacks throughout the day: Clients with major depressive disorder may experience changes in appetite, but offering low-protein snacks is not a specific therapeutic intervention. Balanced meals and snacks are more appropriate to support overall nutrition.

C. Encourage the client to use positive self-talk: Positive self-talk can help challenge and change negative thought patterns that are common in major depressive disorder. Encouraging cognitive restructuring strategies like positive affirmations supports emotional healing and coping.

D. Recommend the client spend time alone in his room: Isolation can worsen depressive symptoms by increasing feelings of loneliness and hopelessness. Encouraging social interaction and structured activities is more helpful in managing depression.

Correct Answer is ["7.5"]

Explanation

Calculation:

Desired dose = 7.5 mg

Available concentration = 5 mg / 5 mL

= 1 mg/mL

Calculate the volume to administer:

Volume to administer (mL) = Desired dose (mg) / Available concentration (mg/mL)

= 7.5 mg / 1 mg/mL

= 7.5 mL

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is assisting in the care of an adolescent. The nurse is reviewing the data collection findings. Select the 5 findings the nurse should report to the provider.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who has major depressive disorder. Which of the following should the nurse include in the plan of care?

Correct Answer is C

Explanation

Correct Answer is ["7.5"]

Explanation

A nurse is reinforcing postoperative teaching with a client who has a prescription for enoxaparin to prevent deep vein thrombosis. Which of the following information should the nurse include in the teaching as a potential adverse effect of this medication?

A nurse is contributing to the development of an in-service training about child maltreatment for a group of pediatric nurses. Which of the following findings should the nurse identify as a risk factor for child maltreatment?

A nurse is assisting in the care of a client who is on isolation for an infection with vancomycin-resistant enterococcus (VRE). Which of the following actions should the nurse take to prevent the spread of infection?

A nurse is assisting in the care of a client who has a fractured femur and is in Buck's traction. Which of the following actions should the nurse take?

A nurse is assisting with the admission of a client who has limited mobility. Which of the following actions is the nurse's priority?

A nurse is collecting data from a child who is 1 hr postoperative following a tonsillectomy. Which of the following findings is the nurse's priority?

A nurse is assisting with the care of a client who is receiving a PCA pump following a hysterectomy. Which of the following findings should the nurse identify as an indicator of unrelieved pain?

A nurse at a provider's office is caring for a client. Select the 3 findings that require immediate follow-up.

A nurse is assisting in the care of an adolescent.

The nurse is reviewing the data collection findings.

Select the 5 findings the nurse should report to the provider.