A nurse is caring for a client in an outpatient clinic.
Click to highlight the findings that require further evaluation, to deselect a finding, click on the finding again.
|
Body System |
Findings |
|
Neurological |
Reports that dizziness and palpitations started 2 months ago. Alert and oriented to person, place, and time |
|
Cardiovascular |
Pedal pulses +1 bilaterally, Pedal edema +1 bilaterally. Capillary refill time 5 seconds for all extremities. Reports no pain with palpation of thorax. |
|
Respiratory |
Fatigue and dyspnea with exertion started 1 week ago. Lungs clear to auscultation bilaterally |
|
Vital Signs |
Heart rate 105/min Respiratory rate 20/min Blood pressure 164/92 mm Hg Oxygen saturation 96% on room air |
Reports that dizziness and palpitations started 2 months ago.
Alert and oriented to person, place, and time
Pedal pulses +1 bilaterally, Pedal edema +1 bilaterally.
Capillary refill time 5 seconds for all extremities.
Fatigue and dyspnea with exertion started 1 week ago.
Lungs clear to auscultation bilaterally
Heart rate 105/min
Blood pressure 164/92 mm Hg
The Correct Answer is ["A","C","D","E","G","H"]
Rationale for correct choices
• Neurological: Reports that dizziness and palpitations started 2 months ago: Persistent dizziness and palpitations may indicate arrhythmias, decreased cardiac output, or early cardiovascular compromise. Although the client is alert and oriented, these symptoms suggest insufficient cerebral perfusion or possible underlying cardiac pathology that requires further evaluation.
• Cardiovascular: Pedal pulses +1 bilaterally, Pedal edema +1 bilaterally, Capillary refill time 5 seconds for all extremities: Diminished pulses, mild edema, and prolonged capillary refill time indicate potential peripheral arterial insufficiency and early signs of fluid overload or heart failure. These findings suggest impaired circulation and warrant further assessment.
• Respiratory: Fatigue and dyspnea with exertion started 1 week ago: New-onset exertional dyspnea and fatigue may be early indicators of compromised cardiac or pulmonary function. Despite clear lung sounds, these symptoms suggest reduced oxygen delivery or early heart failure. Prompt evaluation is required to prevent progression and to identify reversible causes.
• Vital Signs: Heart rate 105/min, Blood pressure 164/92 mm Hg: Tachycardia and hypertension indicate increased cardiac workload and potential risk for end-organ damage. Persistent elevated BP above 140/90 mm Hg is associated with cardiovascular complications, including left ventricular hypertrophy and renal impairment. Monitoring and further evaluation of cardiac function, lifestyle factors, and medication adherence are necessary.
Rationale for incorrect choices
• Neurological: Alert and oriented to person, place, and time: Being alert and oriented reflects intact cognitive function and does not require immediate further evaluation. While neurological changes may arise secondary to cardiac issues, orientation alone is within normal limits and is not concerning. This finding does not indicate acute pathology.
• Respiratory: Lungs clear to auscultation bilaterally: Clear lung sounds suggest no active pulmonary congestion, infection, or obstruction. Although dyspnea is present, the absence of adventitious lung sounds indicates that the respiratory system is not acutely compromised. Further evaluation focuses on cardiac or systemic causes rather than pulmonary pathology.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A","dropdown-group-3":"A"}
Explanation
Rationale for correct choices
• deep vein thrombosis (DVT): The client displays classic findings of DVT, including unilateral leg swelling, warmth, inflammation, and increased calf circumference. These findings, paired with a sedentary lifestyle and recent trauma to the leg, strongly indicate development of a thrombus in the affected extremity.
• Unequal leg circumference: The right calf measures 45.72 cm while the left measures 40.64 cm, showing significant unilateral swelling. A difference greater than 3 cm is strongly associated with DVT due to venous obstruction and impaired return, causing fluid accumulation and increased limb girth.
• Ultrasound results: The duplex ultrasound shows loss of venous compressibility and a thrombus in the right leg. These findings are diagnostic for DVT, confirming venous obstruction and establishing the cause of the client’s symptoms and leg swelling.
Rationale for incorrect choices
• undiagnosed fracture: A fracture would typically produce severe pain, deformity, or inability to bear weight, none of which are strongly present. The ultrasound confirms thrombosis, and the symptoms align more with venous obstruction than bone injury.
• cellulitis of a leg bone: Cellulitis usually presents with diffuse skin redness, warmth, and often fever. Although the leg is warm and inflamed, the presence of a venous thrombus on ultrasound and significant calf size difference more accurately support DVT rather than an infectious process.
• Difficulty walking: Difficulty walking can occur from many causes, such as arthritis or recent injury, and is not specific enough to confirm DVT. Objective findings like limb circumference and ultrasound imaging better demonstrate the underlying condition.
Correct Answer is B
Explanation
Rationale:
A. Assign the AP to ask the client if she has taken her antidiabetic medication today: Asking about medication adherence is part of assessment and requires clinical judgment. Delegating this task to an AP is inappropriate because it involves interpreting client responses and making clinical decisions.
B. Determine if the AP has the skills to perform the test: Before delegating any task, the nurse must verify that the AP is competent and trained to perform the procedure safely. Ensuring skill competency protects the client from harm and aligns with the nurse’s responsibility for delegation.
C. Have the AP check the medical record for prior blood glucose test results: Reviewing medical records and interpreting trends involves clinical judgment and falls outside the typical scope of practice for an AP. This task should remain with the licensed nurse.
D. Help the AP perform the blood glucose test: Assisting the AP is not necessary if the AP is competent and has been properly trained. The nurse’s role is to delegate appropriately, supervise as needed, and ensure safe completion, rather than performing the task alongside the AP.
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