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
Explanation
Rationale:
A. Ensuring that the stool specimen does not contain urine helps to prevent false-positive results, as blood from urine could interfere with the test.
B. Each fecal occult blood test should be performed using a fresh stool specimen to ensure accuracy.
C. Having the client defecate into a bedpan with water is unnecessary and may interfere with the test.
D. Standard precautions, including wearing gloves, are sufficient for handling stool specimens; sterile gloves are not required for this procedure.
Correct Answer is B
Explanation
Rationale:
A. Using the incentive spirometer is important for preventing atelectasis, but it does not prevent orthostatic hypotension.
B. Dangling the legs over the side of the bed before standing helps reduce the risk of orthostatic hypotension by allowing the body to gradually adjust to the change in position.
C. Increasing protein intake is important for wound healing and tissue repair, but it does not prevent orthostatic hypotension.
D. Performing regular isometric exercises is important for maintaining muscle strength and mobility, but it does not prevent orthostatic hypotension.
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