A nurse is caring for a group of clients. Which of the following findings should the nurse report to the provider?

An adolescent who has a BP of 132/82 mm Hg

A 3-month-old infant who has a respiratory rate of 30/min

An 18-month-old toddler who has a heart rate of 68/min

A school-age child who has a rectal body temperature of 37.3° C (99.1° F)

Answer and Explanation

The Correct Answer is C

A. A blood pressure of 132/82 mm Hg in an adolescent is within the normal range for their age group. It does not require immediate reporting to the provider.

B.   A respiratory rate of 30 breaths per minute in a 3-month-old infant is within the expected (typically 25-40 breaths per minute).

C.   A heart rate of 68 beats per minute in an 18-month-old toddler is below the normal range (typically 70-110 beats per minute) and should be reported g to the provider.
D.   A rectal body temperature of 37.3° C (99.1° F) in a school-age child is within the normal range (typically 36.5-37.5° C or 97.7-99.5° F). It does not require immediate reporting to the provider.

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Correct Answer is A

Explanation

A. Applying warm compresses can help to improve blood flow and relieve pain in areas affected by a sickle cell crisis. This is a beneficial intervention.

B. Decreasing fluid intake is not recommended. Maintaining hydration is important in the management of sickle cell disease, as it helps to prevent dehydration and reduces the risk of sickling.

C. Furosemide is a diuretic and is not typically used in the treatment of a sickle cell crisis.
It is not an appropriate intervention in this situation.

D. Contact precautions are not necessary for a sickle cell crisis. This crisis is not a contagious condition. Standard precautions for infection control should be followed.

A. Administer an antidepressant to the client. B. Assist the client in completing his ADLs. C. Ask the client if he is considering harming himself. D. Encourage the client to attend a group therapy session.

Correct Answer is C

Explanation

A. Administering an antidepressant is an important intervention for a client with major depressive disorder. However, before initiating any treatment, it is crucial to assess the client's risk for self-harm or suicidal ideation.

B. Assisting the client in completing activities of daily living (ADLs) is important for their overall well-being, but the most immediate concern for a client with major depressive disorder is to assess their safety and risk for self-harm.

C. Correct. Assessing the client's risk for self-harm or suicidal ideation is the first priority.
This information will help determine the level of intervention and support needed.

D. Encouraging the client to attend group therapy is a valuable intervention, but it is not the first priority. Safety concerns must be addressed before implementing other
therapeutic interventions.

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A nurse is caring for a group of clients. Which of the following findings should the nurse report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a school-age child who is experiencing a sickle cell crisis. Which of the following actions should the nurse take

Correct Answer is A

Explanation

A nurse is caring for an adolescent who has a major depressive disorder. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

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