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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","D","G"]

Explanation

Choice A reason:

"Try using an abdominal support belt". This statement is incorrect. There is no indication or relevance for using an abdominal support belt based on the vital signs and weight provided. This statement is not appropriate for the client's teaching.

Choice B reason:

"Take hot showers to help relieve itching" This statement is incorrect. Itching is not mentioned in the vital signs and weight provided. Additionally, taking hot showers might not be relevant to the client's condition or needs. This statement is not appropriate for the client's teaching.

Choice C reason:

"Wear loose-fitting clothing" This is an appropriate statement for the client's teaching. Wearing loose-fitting clothing can provide comfort and allow better circulation, which might be helpful for some clients.

Choice D reason:

"Wear flat or low-heeled shoes" This is an appropriate statement for the client's teaching. Wearing flat or low-heeled shoes can help provide comfort and support, especially if the client has any foot or back issues.

Choice E reason:

"You can douche twice weekly." Douche is not relevant to the vital signs and weight provided, and it is generally not recommended for routine use as it can disrupt the natural balance of vaginal flora. This statement is not appropriate for the client's teaching.

Choice F reason:

"Eat two large meals a day." This statement does not align with a healthy eating pattern, and it might not be appropriate for the client's health needs. The recommendation for a balanced diet usually includes several smaller meals throughout the day. This statement is not appropriate for the client's teaching.

Choice G reason:

"You should avoid fried foods." This is an appropriate statement for the client's teaching. Avoiding fried foods can be beneficial for overall health, especially if the client is trying to manage weight or maintain a balanced diet.

A. "What are the voices telling you?" B. "Have you taken your medication today?" C. "I realize the voices are real to you, but I don't hear anything." D. "How long have you been hearing the voices?"

Correct Answer is A

Explanation

The correct answer is Choice A.

Choice A rationale: “What are the voices telling you?” This is the priority response because it directly addresses the client’s immediate concern. The nurse is acknowledging the client’s experience and seeking to understand more about it. This can help the nurse assess the potential for harm to the client or others, as the voices may be instructing the client to engage in dangerous behaviors.

Choice B rationale: “Have you taken your medication today?” While medication adherence is important in managing schizophrenia, this response does not address the client’s immediate concern about hearing voices. It may also come across as dismissive of the client’s experience.

Choice C rationale: “I realize the voices are real to you, but I don’t hear anything.” This response validates the client’s experience, but it does not gather further information about what the voices are saying, which is crucial for assessing safety.

Choice D rationale: “How long have you been hearing the voices?” While this question is relevant for understanding the client’s history and the progression of their illness, it is not the priority response. The immediate concern should be what the voices are saying to assess for potential harm.

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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 in an outpatient clinic is caring for a client Vital Signs BP 124/68 mm Hg Heart rate 80/min Temperature 37° C (98.6° F) Respiratory rate 16/min Weight 67.1 kg (148 lb)

Correct Answer is ["C","D","G"]

Explanation

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Correct Answer is A

Explanation

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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.)