A nurse is conducting discharge teaching to parents about the care of their infant after cardiac surgery. The nurse instructs the parents to notify the physician of what conditions occur. (Select all that apply.).
Respiratory rate of 36 breaths/minute at rest.
Appetite slowly increasing.
Temperature above 37.7° C (100° F).
New, frequent coughing.
Turning blue or bluer than normal.
Correct Answer : A,C,D,E
The correct answer is choices A, C, D, and E.
Choice A rationale:
A respiratory rate of 36 breaths/minute at rest is concerning in a pediatric client, as it may indicate respiratory distress or an underlying respiratory condition.
Choice B rationale:
An increasing appetite is generally a positive sign and not typically concerning unless accompanied by other symptoms.
Choice C rationale:
A temperature above 37.7° C (100° F) is concerning as it indicates fever, which could be a sign of infection or other medical conditions.
Choice D rationale:
New, frequent coughing is concerning as it may indicate respiratory infections, asthma, or other respiratory issues.
Choice E rationale:
Turning blue or bluer than normal (cyanosis) is a serious symptom indicating inadequate oxygenation and requires immediate medical attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E","F"]
Explanation
Choice A rationale:
A review of systems is essential in a health history because it helps in understanding the patient's overall health status and can reveal symptoms or issues that the patient might not consider significant. This information aids in making a comprehensive assessment.
Choice D rationale:
Height, weight, and BMI data are crucial parameters to assess a patient's nutritional status and overall health. These measurements help in identifying obesity, malnutrition, or other health-related issues.
Choice E rationale:
Diet and nutritional intake provide insights into the patient's eating habits, dietary restrictions, allergies, and potential deficiencies. This information is vital for assessing the patient's overall health and planning appropriate interventions.
Choice F rationale:
Family medical history is valuable as it helps in identifying genetic predispositions, hereditary diseases, and other health conditions that might run in the family. This information is crucial for understanding the patient's risk factors and developing a personalized healthcare plan. Choice B and C rationales: Physical assessment is indeed essential in healthcare, but it is not a part of the health history, which specifically focuses on the patient's past and current health status, medical conditions, medications, allergies, surgeries, and lifestyle habits. Similarly, a sexual history is important, especially for specific medical conditions, but it might not be relevant to every patient and might not always be included in the general health history.
Correct Answer is D
Explanation
Choice A rationale:
Limiting the time spent on exploration of intimate topics may result in incomplete information, leading to potential gaps in the patient's health history. It's essential to create a safe and supportive environment, allowing the patient to share necessary information freely.
Choice B rationale:
Avoiding questions that may embarrass the patient could prevent the nurse from gathering crucial information related to the patient's reproductive health. Sensitivity and non-judgmental communication are essential, enabling the patient to openly discuss sensitive topics.
Choice C rationale:
Using accepted medical terminology is important, but it should be balanced with clear communication. Complex medical terms might confuse the patient. It's essential to use language that the patient can understand, ensuring effective communication and a better understanding of their health.
Choice D rationale:
This statement indicates a correct understanding of the best approach when obtaining a reproductive health history. Explaining the purpose for the questions asked and how the information will be used builds trust and helps the patient feel more comfortable sharing sensitive information. It also ensures that the patient understands the relevance of the questions, fostering open communication between the patient and the healthcare provider.
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