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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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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Correct. Performing a sterile dressing change falls within the scope of practice for a licensed practical nurse (LPN).

B. Incorrect. Discharge teaching often involves complex information and considerations, which are typically better suited for a registered nurse.

C. Incorrect. An admission assessment requires comprehensive assessment skills that are typically performed by registered nurses.

D. Incorrect. Completing assessments related to complex neurological changes, such as the Glasgow Coma Scale for a stroke, is typically within the scope of a registered nurse.

A. Take a 1-hr nap during the day. B. Perform exercises prior to bedtime. C. Eat a light snack before bedtime. D. Stay in bed at least 1 hr if unable to fall asleep.

Correct Answer is C

Explanation

A. Incorrect. Napping for an hour during the day can disrupt nighttime sleep.

B. Incorrect. Exercising prior to bedtime can stimulate the body and interfere with falling asleep.
C. Correct. Eating a light snack before bedtime can help prevent waking due to hunger during the night.
D. Incorrect. Staying in bed if unable to fall asleep can lead to frustration and associating the bed with wakefulness.

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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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Correct Answer is C

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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.)