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 C
Explanation
A. Verifying the bilirubin level of the tube contents is not a reliable method for confirming tube placement and may not provide accurate information.
B. Auscultating for air insufflation can help detect tube placement in the respiratory tract but may not reliably confirm placement in the gastrointestinal tract.
C. Requesting a chest x-ray is the most reliable method for confirming the placement of a feeding tube, as it allows visualization of the tube's position relative to anatomical landmarks.
D. Checking the pH level of gastric contents can help differentiate between gastric and respiratory placement but may not provide definitive confirmation of tube placement.
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