A nurse is caring for a client in an emergency department (ED).
Exhibits
Which of the following findings in the client's medical record requires follow-up by the nurse? Select all that apply

Blood pressure

Syncope

ECG

Albumin

Answer and Explanation

Correct Answer : A,B,C,D,E,F

Rationale:

A. Blood pressure: Orthostatic hypotension is evident from the drop in systolic and diastolic pressure when standing, indicating fluid and electrolyte imbalance. This may reflect volume depletion due to purging and requires monitoring to prevent fainting or falls.

B. Syncope: The client reports repeated fainting episodes, a red flag when paired with orthostatic hypotension and electrolyte disturbances. This suggests unstable cardiovascular status and raises the risk of injury or sudden cardiac events.

C. ECG: Sinus tachycardia with premature ventricular contractions indicates cardiac irritability likely due to electrolyte imbalance, especially hypokalemia. Continuous cardiac monitoring and correction of abnormalities are needed.

D. Albumin: An albumin level of 2.6 g/dL indicates significant malnutrition and protein deficiency, compromising immune function and wound healing. This also suggests a chronic issue requiring dietetic intervention and nutritional rehabilitation.

E. Potassium: Potassium at 3.0 mEq/L is dangerously low and a known contributor to cardiac arrhythmias and muscle weakness. Replenishment and close monitoring are critical to avoid complications such as cardiac arrest.

F. Sodium: Although sodium is only slightly low at 134 mEq/L, in the context of purging and poor intake, this could indicate dilutional hyponatremia. It increases seizure risk and needs assessment of fluid status and intake behaviors.

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Correct Answer is B

Explanation

Rationale:

A. Place the client upright on a donut-shaped cushion: Donut-shaped cushions are not recommended because they create uneven pressure distribution, which can worsen ischemia around pressure points rather than relieve it, potentially delaying healing.

B. Teach the client to shift his weight every 15 min while sitting: Frequent weight shifting relieves pressure on the ischial area and promotes circulation, helping to prevent progression of a stage 1 pressure injury. This intervention supports client independence and tissue integrity.

C. Assess pressure points every 24 hr: Pressure points should be assessed more frequently than once daily, especially in high-risk clients. Routine skin assessments at least once per shift are critical for early detection of pressure injury progression.

D. Turn and reposition the client every 3 hr while in bed: The standard recommendation is to reposition immobile clients at least every 2 hours in bed to redistribute pressure and reduce the risk of further skin breakdown. Extending intervals increases risk of injury.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

Explanation

Rationale for Correct Choices:

Serotonin syndrome: The client presents with restlessness, fever, abdominal pain, and disorientation all classic signs of serotonin syndrome. These symptoms developed after a recent dose increase of a serotonergic medication, indicating a likely adverse drug reaction.
Adverse effects of paroxetine: Paroxetine, an SSRI, can cause serotonin syndrome, especially when recently increased or combined with other serotonergic agents. The timing of the dose escalation aligns with the emergence of the client’s acute symptoms.

Rationale for Incorrect Choices:

Psychosis: While disorientation is present, there is no evidence of hallucinations, delusions, or loss of reality testing, which are essential features of psychosis.
Mania: The client does not show signs of elevated mood, grandiosity, pressured speech, or risky behavior, which are typical of mania.
Anxiety: Although anxiety is part of the client’s history, the sudden onset of fever and autonomic instability points more clearly to a toxic reaction rather than worsening anxiety.
Fluoxetine discontinuation: Fluoxetine has a long half-life, and discontinuation typically causes delayed withdrawal symptoms like dizziness or mood swings not the acute systemic symptoms noted here.

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A nurse is caring for a client in an emergency department (ED).Exhibits Which of the following findings in the client's medical record requires follow-up by the nurse? Select all that apply

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Explanation

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A nurse is caring for a client in an emergency department (ED).
Exhibits
Which of the following findings in the client's medical record requires follow-up by the nurse? Select all that apply