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A nurse is caring for a client in a long-term care facility.

Exhibits
Which of the following assessment findings require follow-up by the nurse? Select all that apply.

Vocal quality

Blood pressure

Albumin

BMI

Dentition

Bowel pattern

Lung sounds

Temperature

Secretions

Posture

Answer and Explanation

Correct Answer : A,D,F,G,H,I,J

A. Vocal quality – The client’s voice is hoarse and weak on Day 30, which may indicate dehydration, malnutrition, or an underlying respiratory issue.

B. Blood pressure – The client's blood pressure has slightly decreased but remains within a normal range, so it does not require immediate follow-up.

C. Albumin – Serum albumin levels are still within normal range.

D. BMI – The drop from 20 to 19 suggests unintentional weight loss, which could indicate malnutrition, inadequate intake, or an underlying illness.

E. Dentition –No difficulty in chewing reported.

F. Bowel pattern – The client has constipation for three days, which may require intervention to prevent complications like fecal impaction or discomfort.

G. Lung sounds – Diminished breath sounds at the bases may indicate fluid accumulation, atelectasis, or respiratory infection, requiring further evaluation.

H. Temperature – The client’s fever (38.1°C/100.6°F) suggests a possible infection and requires monitoring for underlying illness.

I. Secretions – Thick oral secretions may indicate dehydration, poor oral hygiene, or a swallowing issue, requiring follow-up to prevent aspiration.

J. Posture – The client’s slumped posture and fatigue could indicate weakness, nutritional deficiencies, or an underlying neurological or musculoskeletal problem.

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Correct Answer is B

Explanation

A. "I can exercise as late as 1 hour before bedtime." Exercise close to bedtime can increase alertness and make it harder to fall asleep. It is recommended to finish exercising at least 3-4 hours before bedtime.

B. "I should reduce my fluid intake 2 hours before bedtime." Reducing fluid intake before bedtime helps minimize nocturia, which can disrupt sleep.

C. "I should take a 1-hour nap each day." Long or frequent naps can interfere with nighttime sleep. If naps are needed, they should be limited to 20-30 minutes earlier in the day.

D. "I can eat a large meal as late as 1 hour before bedtime." Eating a heavy meal before bed can cause discomfort and acid reflux, which may disrupt sleep. A light snack is preferable.

A. Takes several steps on tip toes B. Walks without assistance using a wide stance C. Has an accentuated cervical curvature when standing D. Stands with the feet turned slightly inward

Correct Answer is B

Explanation

A. Takes several steps on tiptoes. Typically develops around 24 months, not 15 months.

B. Walks without assistance using a wide stance. At 15 months, toddlers typically walk independently with a wide stance to improve balance.

C. Has an accentuated cervical curvature when standing. Not an expected motor milestone.

D. Stands with the feet turned slightly inward. Inward foot positioning can indicate a developmental delay or foot abnormality.

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A nurse is caring for a client in a long-term care facility. Exhibits Which of the following assessment findings require follow-up by the nurse? Select all that apply.

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A nurse is caring for a client in a long-term care facility.

Exhibits
Which of the following assessment findings require follow-up by the nurse? Select all that apply.