A nurse is caring for a client.

Exhibits

The nurse is assessing the client.

Select the 4 findings that require immediate follow-up.

Heart rate

Sleep pattern

Hallucinations

skin turgor

Hygiene

Answer and Explanation

Correct Answer : A,C,D,E

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 pattern. While lack of sleep is concerning and a clear symptom of mania, it is a behavioral health issue that typically does not require immediate physiological intervention unless it leads to severe exhaustion or psychosis. It should be addressed, but is not the top priority.
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. Hygiene. The client's unclean appearance reflects self-neglect, a common feature of psychiatric decompensation, and may indicate inability to meet basic needs. This requires prompt attention to prevent complications like infection and assess for functional impairment, though it is secondary to life-threatening physiological or safety concerns.

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Correct Answer is C

Explanation

A. Place the client in a supine position. As clients near the end of life, the supine position may compromise breathing. A semi-Fowler’s or lateral position is usually preferred to promote comfort and respiratory ease.
B. Remind the client to eat scheduled meals daily. At the end of life, appetite typically decreases, and forcing food can cause discomfort. Nutrition should be offered based on the client's desire, not forced on a strict schedule.
C. Offer the client a blanket to keep warm. Clients nearing death often experience peripheral circulation decline, leading to feelings of coldness. Providing a blanket promotes comfort and warmth without being invasive.
D. Speak in a loud tone when addressing the client. Loud speech can be disorienting and distressing, especially if the client is already weak or confused. Use a calm, clear, and gentle tone to provide comfort and maintain dignity.

A. Changes from prone to sitting B. Rolls from back to abdomen C. Sits steadily unsupported D. Rolls from back to side

Correct Answer is D,B,C,A

Explanation

D. Rolls from back to side usually occurs around 4 months of age as the infant begins developing trunk strength.

B. Rolls from back to abdomen typically follows at around 5 to 6 months, indicating improved coordination and strength.

C. Sits steadily unsupported usually develops around 8 months, showing advanced balance and postural control.

A. Changes from prone to sitting is a more complex skill that typically appears around 10 months, requiring significant core strength and motor planning.

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A nurse is caring for a client. Exhibits The nurse is assessing the client. Select the 4 findings that require immediate follow-up.

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Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has terminal cancer and is nearing the end of life. Which of the following interventions should the nurse include?

Correct Answer is C

Explanation

A nurse is teaching a group of parents about expected development of gross motor skills during infancy. The nurse should teach that the following developmental tasks are expected to occur in what order? (Move the steps into the box, placing them in the order of performance. Use all the steps.)

Correct Answer is D,B,C,A

Explanation

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A nurse is caring for a client.

Exhibits

The nurse is assessing the client.

Select the 4 findings that require immediate follow-up.