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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Bulging anterior fontanel. A bulging fontanel is associated with increased intracranial pressure, not dehydration. Dehydration is more likely to cause a sunken fontanel.
B. Decreased temperature. Dehydrated infants typically exhibit normal or elevated temperatures, especially if they have an underlying infection or fever. A decreased temperature is not a common sign of dehydration.
C. Hypertension. Dehydration more commonly leads to hypotension or normal blood pressure, depending on severity. Hypertension is not an expected finding in an infant with fluid volume loss.
D. Oliguria. Decreased urine output (oliguria) is a classic and expected sign of dehydration in infants. It indicates the kidneys are conserving fluid due to inadequate intake and fluid loss from vomiting and diarrhea.
Correct Answer is A
Explanation
A. "Purchase a gift to give to your son from your baby." This is an effective strategy to help a young child feel included and valued, easing the transition and reducing potential jealousy. It fosters a positive emotional connection between the older sibling and the newborn.
B. "Make sure you are holding your baby when your son comes to visit you in the hospital." This may unintentionally make the child feel replaced or left out. It’s better for the parent to be free to hug and reassure the older child during the initial visit.
C. "Use medical terminology when teaching your son about your new baby." Medical terms may confuse or overwhelm a 4-year-old. Simple, age-appropriate language is more effective in helping the child understand the upcoming changes.
D. "Surprise your son with a new bedroom after you bring the baby home." Sudden changes can be disorienting or upsetting for young children. Involving them in the transition process before the baby arrives helps foster a sense of control and comfort.
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