A nurse is reviewing the medical record of a client.
Click to highlight below the findings that require immediate follow-up.
Body system/Findings
Neurological- Alert and oriented to person, place, and time; deep tendon reflexes 4+
Musculoskeletal - Generalized weakness with equal bilateral muscle strength and mild leg cramping
Respiratory- Lungs clear
Cardiovascular- Heart rate irregular: Heart rate 95/min
Gastrointestinal- Bowel sounds hyperactive x 4 quadrants
Neurological- Alert and oriented to person, place, and time; deep tendon reflexes 4+
Musculoskeletal - Generalized weakness with equal bilateral muscle strength and mild leg cramping
Respiratory- Lungs clear
Cardiovascular- Heart rate irregular: Heart rate 95/min
Gastrointestinal- Bowel sounds hyperactive x 4 quadrants
The Correct Answer is ["D","E"]
Rationale:
A. These neurological findings are within normal limits and do not require immediate follow-up.
B. These musculoskeletal findings are not indicative of an emergency and can be addressed during routine care.
C. Clear lung sounds are a normal finding and do not require immediate follow-up.
D. An irregular heart rate may indicate an arrhythmia or other cardiovascular issue that requires further assessment and intervention.
E. Hyperactive bowel sounds can indicate a variety of gastrointestinal issues, including bowel obstruction or ileus, which may require immediate intervention or further investigation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
A. The client has hypertension and high sodium levels, indicating fluid retention, so a diuretic may be prescribed to help manage these conditions.
B. The client reports difficulty sleeping without drinking several beers a night, indicating a potential alcohol problem. Limiting alcohol intake is a common recommendation for clients with this issue.
C. The client has elevated LDL cholesterol, indicating high-fat intake, so limiting fat intake can help manage this.
D. The client has elevated sodium levels, so reducing sodium intake can help manage this.
E. There is no indication for an antibiotic prescription based on the client's symptoms and lab results.
F. There is no indication of high potassium levels, so limiting foods high in potassium is not necessary.
Correct Answer is B
Explanation
Rationale:
A. This response is judgmental and may cause the client to feel guilty or defensive.
B. This response shows empathy and respect for the client's decision.
C. This response may be appropriate if the client needs further information or counseling but should not be the initial response.
D. This response is confrontational and may cause the client to become defensive.
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