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 {"dropdown-group-1":"D","dropdown-group-2":"B"}
Explanation
- Deep vein syndrome: This is not a recognized condition. The intended term may have been deep vein thrombosis (DVT), which is a valid orthopedic complication, but the clinical findings in this scenario point more urgently toward compartment syndrome and infection.
- Osteomyelitis: The client has an open fracture with drainage from the splint, a significantly elevated WBC count (28,000/mm³), and a high fever (38.9°C / 102°F). These findings suggest the development of a bone infection (osteomyelitis), especially in the context of recent surgery and internal fixation.
- Fat embolism syndrome: While fat embolism is a risk with long bone fractures, this client is not displaying key hallmark signs such as respiratory distress, petechiae, or altered mental status. The findings are more consistent with infection and circulatory compromise.
- Compartment syndrome: The client has classic signs including cool foot, numbness, inability to move toes, absent pulses, delayed capillary refill, and increased pain. These are hallmark signs of neurovascular compromise from compartment syndrome, a surgical emergency.
Correct Answer is D
Explanation
A. Rubeola (measles). Rubeola is transmitted through airborne particles and requires airborne precautions, including the use of an N95 respirator and placement in a negative pressure room. Droplet precautions would not provide sufficient protection due to the small particle size and long-range transmission.
B. Varicella (chickenpox). Varicella requires both airborne and contact precautions because it spreads via airborne respiratory droplets and direct contact with lesions. A client with varicella must be isolated in a negative pressure room and healthcare workers should use full PPE.
C. Tuberculosis. Tuberculosis is caused by Mycobacterium tuberculosis and is spread through airborne droplet nuclei, which remain suspended in the air for extended periods. It requires airborne precautions, including an N95 respirator and isolation in a specialized room.
D. Pertussis (whooping cough). Pertussis is a highly contagious bacterial infection that spreads through large respiratory droplets during coughing or sneezing. Droplet precautions are required, which include wearing a surgical mask when within 3 feet of the client and practicing proper hand hygiene to prevent transmission.
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