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A nurse is caring for a client who presents to the emergency department.

Exhibits
A nurse is reviewing the client's record. Which of the following client findings indicate the need for further evaluation?
(Select All that Apply.)

Weight

Report of cough

Blood pressure

Travel history

Sputum characteristics

Temperature

Heart Rate

Answer and Explanation

Correct Answer : A,D,E,F,G

Based on the information provided, the nurse should consider the following client findings for further evaluation:

A. Weight: The client's weight loss of 5 pounds (2.26 kg) over the last week needs further evaluation as it could be indicative of an underlying health issue.

D. Travel history: The client's recent travel to South Africa and the presence of respiratory symptoms raises concerns about possible exposure to infectious diseases, including tuberculosis, which is more prevalent in certain regions. Further evaluation of the travel history is essential.

E. Sputum characteristics: The client's report of "blood-tinged sputum" is concerning and should be evaluated further to rule out potential serious respiratory conditions.

F. Temperature: The presence of a "low-grade fever" should be further evaluated to assess the possible infectious etiology of the client's symptoms.

G. Heart Rate: The heart rate should be assessed further as an elevated heart rate could indicate an underlying systemic infection or other health issues.

The following client findings do not necessarily indicate the need for further evaluation in this context:

B. Report of cough: The client's report of a cough is the primary reason for their presentation to the emergency department and will, of course, be further evaluated as part of the assessment.

C. Blood pressure: Though monitoring blood pressure is essential, the information provided does not indicate any specific concerns regarding the client's blood pressure at this point.

A comprehensive assessment and further evaluation are necessary to determine the underlying cause of the client's symptoms. The nurse should collaborate with other healthcare professionals to conduct appropriate diagnostic tests and investigations to establish a diagnosis and provide appropriate care.

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Correct Answer is B

Explanation

A. Incorrect. Suggesting finding alternative remedies through an online support group may not provide accurate or safe information.
B. Correct. This response acknowledges the client's interest and offers to provide guidance in selecting a safe alternative practitioner. It's important to ensure that any alternative therapies are safe and evidence-based.
C. Incorrect. While it's important to respect the client's personal beliefs, the nurse should also ensure that the chosen therapies are safe and effective.
D. Incorrect. Waiting for the provider to suggest alternative therapies may delay the client's access to safe and effective treatments.

A. "Documentation of sensitive material is performed by the charge nurse." B. You will be given access to the medical records of every client in the facility. C. You will be asked to change your password once per year. D. "Information Technology will install a firewall to secure client information."

Correct Answer is D

Explanation

A. Incorrect. Documentation of sensitive material might have designated personnel, but this information does not need to be limited to the charge nurse.

B. Incorrect. Access to medical records should be limited to those with a need for that information, not every nurse in the facility.

C. Incorrect. Most facilities require more frequent password changes (e.g., every 90 days) to enhance security. Therefore, this statement may be inaccurate depending on the facility's policy.

D. Correct. Firewalls are security systems that are used to protect computer networks from unauthorized access. They are an important component of any computerized documentation system.

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A nurse is caring for a client who presents to the emergency department. Exhibits A nurse is reviewing the client's record. Which of the following client findings indicate the need for further evaluation? (Select All that Apply.)

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A nurse is caring for a client who presents to the emergency department.

Exhibits
A nurse is reviewing the client's record. Which of the following client findings indicate the need for further evaluation?
(Select All that Apply.)