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 |
deep tendon reflexes 4+
Heart rate irregular
Bowel sounds hyperactive x 4 quadrants
Generalized weakness with equal bilateral muscle strength and mild leg cramping
Lungs clear
Heart rate 95/min
Alert and oriented to person, place, and time;
The Correct Answer is ["A","B","C","D"]
An irregular heart rhythm could indicate potential cardiovascular issues. Additionally, deep tendon reflexes graded at 4+ suggest hyperreflexia, which may be associated with neurological disorders and should be investigated further.
Hyperactive bowel sounds in all four quadrants could indicate gastrointestinal hypermotility, which might require prompt assessment to determine the underlying cause.
Generalized weakness and mild leg cramping also require follow-up to determine the cause.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) The stoma protrudes slightly from the abdomen. - A slightly protruding stoma is a normal finding following colostomy surgery and does not require reporting.
B) The stoma bleeds lightly when touched. - Minor bleeding may occur, especially in the immediate postoperative period, and typically resolves without intervention.
C) The stoma appears dark in color. - A dark or dusky stoma may indicate compromised blood supply and should be reported promptly to the provider.
D) The stoma is draining a small amount of liquid stool. - Stoma output varies among individuals and can include liquid stool, which is a normal finding post-colostomy surgery.
Correct Answer is A
Explanation
A) Request a change in the medication route to PO. - If the client is afraid of needles, and if methadone can be effectively administered orally (PO), changing the route of administration to oral may be a reasonable alternative.
B) Remind the client that they must receive the medication as prescribed. - While important to ensure adherence to the prescribed treatment, it's also essential to address the client's concerns and preferences.
C) Tell the client not to worry because the pain will be temporary. - Dismissing the client's fear with reassurance about temporary pain may not adequately address their anxiety.
D) Ask one of the client's loved ones to encourage them to receive the IM medication.
- Involving loved ones may be helpful, but the client's preference should be respected, and alternative options should be explored.
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