A nurse is caring for a client.
The nurse is assessing the client.
Select the 4 findings that require immediate follow-up.
Heart rate
Sleep pattern
Hallucinations
skin turgor
Hygiene
Correct Answer : A,B,C,D
A. Heart rate. The client has a heart rate of 120/min, which is tachycardia and may indicate dehydration, mania-related hyperactivity, or a response to poor nutritional status. This requires immediate follow-up to assess for cardiovascular strain or fluid imbalance.
B. Sleep deprivation (has not slept for 2 days) can exacerbate mania, contribute to delirium, and impair judgment. This requires prompt intervention to ensure safety and stabilization.
C. Hallucinations. The client is responding to internal stimuli, indicating active psychosis, which poses a safety risk to the client and others. Hallucinations require immediate intervention to stabilize mental health and prevent harm.
D. Skin turgor. Poor skin turgor suggests dehydration, which is a priority physiological concern, especially when paired with tachycardia and failure to recall last food intake. This finding indicates the need for fluid and electrolyte evaluation and possible replacement.
E. Poor hygiene is important for overall care but is not an immediate threat to the client’s safety or physiological stability. It can be addressed after urgent medical and psychiatric concerns are managed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Respiratory rate 10/min. This is the priority finding because it suggests respiratory depression, a serious side effect of magnesium sulfate therapy. Magnesium acts as a CNS depressant, and a respiratory rate below 12/min is a potential sign of magnesium toxicity, which can lead to respiratory arrest if not promptly addressed.
B. 2+ deep-tendon reflexes. This indicates normal neuromuscular function and is actually a reassuring finding in a client receiving magnesium sulfate. Reflexes are typically monitored to detect early signs of toxicity, and a 2+ rating means the dose is likely therapeutic.
C. 3+ pedal edema. While significant, pedal edema is a common feature of preeclampsia and not directly related to magnesium sulfate toxicity. It should be monitored but does not require immediate action compared to respiratory compromise.
D. Urinary output 35 mL/hr. This is slightly above the minimum acceptable output of 30 mL/hr, indicating the kidneys are excreting adequately. While magnesium is excreted renally and output must be monitored, this value does not indicate an acute risk.
Correct Answer is A
Explanation
A. "I will hang a new bag of TPN and IV tubing every 24 hours." This is the correct action. TPN solutions are high in glucose and lipids, which create an ideal environment for bacterial growth. Changing the bag and tubing every 24 hours reduces the risk of infection and sepsis, especially in clients with central lines.
B. "I will obtain the client's weight every other day." Weight should be monitored daily in clients receiving TPN to assess for fluid status, nutritional progress, and potential complications like fluid overload or retention.
C. "I will monitor the client's blood glucose level every 8 hours." Clients receiving TPN require more frequent glucose monitoring, typically every 4 to 6 hours, especially when therapy is initiated, due to the high dextrose content that can cause hyperglycemia.
D. “I will increase the rate of the TPN infusion to ensure the correct amount is given." TPN infusion rates should never be adjusted independently by a nurse. Changes must be made only with a provider’s order, as improper rate adjustments can lead to electrolyte imbalances, hyperglycemia, or fluid overload.
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