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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 C

Explanation

Choice C rationale:

Avoiding consuming foods containing chocolate is important for individuals with gastroesophageal reflux disease (GERD) Chocolate contains substances that can relax the lower esophageal sphincter, allowing stomach acid to flow back into the esophagus, worsening GERD symptoms. Therefore, the nurse should include this information in the discharge teaching to help the client manage GERD effectively.

Choice A rationale:

Taking antacids that contain mint for heartburn is not recommended. Mint can relax the lower esophageal sphincter, similar to chocolate, potentially worsening GERD symptoms. Therefore, clients with GERD should avoid mint-containing products.

Choice B rationale:

Increasing dietary intake of citrus fruits is not advisable for individuals with GERD. Citrus fruits are acidic and can irritate the esophagus, leading to increased reflux symptoms. Clients with GERD should limit or avoid citrus fruits in their diet.

Choice D rationale:

Lying down for 30 minutes after eating a meal is not a recommended practice for individuals with GERD. Instead, clients with GERD should remain upright for at least 2-3 hours after eating to reduce the risk of reflux. Lying down shortly after a meal can worsen symptoms by allowing stomach acid to flow back into the esophagus more easily.

A. "I can visit my nephew who has chickenpox 5 days after the sores have crusted." B. "I should take antibiotics when I have a virus." C. "I should wash my hands for 10 seconds with hot water after working in the garden." D. "I can clean my cat's litter box during my pregnancy."

Correct Answer is A

Explanation

A. Correct. Chickenpox is contagious until the sores have crusted over, which generally takes about 5-7 days. Visiting after this period reduces the risk of infection.
B. Incorrect. Antibiotics are not effective against viruses; they treat bacterial infections.
C. Incorrect. Handwashing should be done with soap and water for at least 20 seconds, not 10 seconds, to effectively remove germs.
D. Incorrect. Cleaning a cat's litter box during pregnancy is not recommended due to the risk of toxoplasmosis, a parasitic infection.

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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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Explanation

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Correct Answer is A

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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.)