Try Naxlex NCLEX-RN (Free-Trial)

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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A. Incorrect. Being suspicious of others is more characteristic of paranoid personality disorder.
B. Incorrect. Ritualistic behavior is more characteristic of obsessive-compulsive personality disorder.
C. Correct. Preoccupation with aging and a fear of losing their physical attractiveness or power is a common trait in individuals with narcissistic personality disorder.
D. Incorrect. Exhibiting separation anxiety is not a defining characteristic of narcissistic personality disorder.

A. Position the client on the affected side for 4 hr following the procedure. B. Place the client in the prone position during the procedure. C. Instruct the client to avoid coughing during the procedure. D. Inform the client that he will be NPO for 6 hr prior to the procedure.

Correct Answer is C

Explanation

A.The client should be positioned on the unaffected side after the procedure, not the affected side.
B.The client is usually seated upright and leaning forward during a thoracentesis, not placed in the prone position.
C.Correct. Instructing the client to avoid coughing during the procedure is important to prevent accidental puncture of the lung.
D.Thoracentesis does not typically require NPO status, as it is not a procedure involving the gastrointestinal tract.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is completing an admission assessment for a client who has narcissistic personality disorder. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

A nurse is planning care for a client who is scheduled for a thoracentesis. Which of the following actions should the nurse plan to take?

Correct Answer is C

Explanation

A nurse is developing an in-service about personality disorders. Which of the following information should the nurse include when discussing borderline personality disorder?

A nurse is caring for a client who is receiving total parenteral nutrition (TPN). The bag has 20 mL remaining to infuse, but a new bag is not readily available. Which of the following actions should the nurse take?

A home health nurse is planning care for an older adult client who has vision loss and takes medications throughout the day.Which of the following actions should the nurse include in the plan?

A newly licensed nurse working at an HIV clinic is reviewing the responsibilities of her position at the clinic. Which of the following tasks should the nurse identify as tertiary prevention?

A nurse at a community health clinic is planning care for an adolescent who recently learned that she is pregnant and is concerned about her ability to afford and care for her baby. Which of the following actions should the nurse take?

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.)