A nurse is caring for a client who has gastroenteritis and is reviewing the client's findings from two days ago and today. Which of the following findings require immediate follow-up?
The client is confused and appears weak.
The client's oral mucosa is dry and tongue is furrowed.
The client's temperature is 37.4° C (99.3° F).
The client's blood pressure is 90/58 mm Hg.
The Correct Answer is A
Choice A reason: Confusion and weakness are signs of dehydration and electrolyte imbalance, which can result from vomiting and diarrhea. These are serious complications that can affect the client's mental status, blood pressure, heart rate, and kidney function. The nurse should report these findings to the provider and monitor the client's vital signs and fluid status.
Choice B reason: Dry oral mucosa and furrowed tongue are also signs of dehydration, but they are less severe than confusion and weakness. The nurse should report these findings to the provider as well, but they are not the most urgent ones.
Choice C reason: A temperature of 37.4° C (99.3° F) is slightly elevated, but not indicative of a fever or infection. The nurse should document this finding, but it does not require immediate follow-up.
Choice D reason: A blood pressure of 90/58 mm Hg is low, but not hypotensive. The nurse should document this finding, but it does not require immediate follow-up.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Cheddar cheese is not a good food choice for maintaining water intake, as it contains only about 37% water¹. Cheese and other dairy products are also high in sodium, which can increase the water loss through urine.
Choice B reason: Broccoli is a good food choice for maintaining water intake, as it contains about 89% water². Broccoli and other vegetables are also rich in vitamins, minerals, and antioxidants, which can benefit the child's health and hydration.
Choice C reason: Whole-wheat bread is not a good food choice for maintaining water intake, as it contains only about 35% water³. Bread and other grains are also high in carbohydrates, which can increase the water retention in the body.
Choice D reason: Almonds are not a good food choice for maintaining water intake, as they contain only about 4% water⁴. Almonds and other nuts are also high in fat and calories, which can contribute to weight gain and inflammation.
Correct Answer is B
Explanation
Choice A reason: Reducing caloric intake by 200 calories a day may not be enough to achieve significant weight loss for a client who is obese. The recommended daily calorie deficit for weight loss is 500 to 750 calories, which can result in a loss of 1 to 1.5 pounds per week¹.
Choice B reason: Losing 5 percent of body weight can improve glycemic control and reduce the need for glucose-lowering medications for a client who has type 2 diabetes. Studies have shown that weight loss of 5 to 10 percent can lower HbA1c levels by 0.5 to 1.0 percentage points².
Choice C reason: Exercising for 30 minutes three times a week may not be sufficient to lose 1 pound per week. The recommended amount of physical activity for weight loss is at least 150 minutes of moderate-intensity aerobic exercise per week, plus resistance training at least twice a week³.
Choice D reason: Drinking 16 ounces of apple juice is not advisable if the blood glucose level drops during exercise, as it can cause hyperglycemia. Apple juice contains about 48 grams of carbohydrates, which is equivalent to four servings of glucose tablets⁴. The recommended treatment for hypoglycemia is to consume 15 to 20 grams of fast-acting carbohydrates, such as glucose tablets, gel, or juice, and recheck the blood glucose level after 15 minutes⁵.
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