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) Tuna fish - Tuna fish is a source of animal protein and is not suitable for a lacto- vegetarian diet, which excludes meat but includes dairy.
B) Clam chowder - Clam chowder typically contains seafood and is not suitable for a lacto-vegetarian diet.
C) Cheese - Cheese is a dairy product and is suitable for a lacto-vegetarian diet, which includes dairy but excludes meat.
D) Chicken - Chicken is a source of animal protein and is not suitable for a lacto- vegetarian diet.
Correct Answer is ["A","C","E","F","G"]
Explanation
A. Ensure the oxygen delivery system is at least 8 feet from any heat source- This is important to prevent any risk of fire or combustion around the oxygen source.
B. Adjust the oxygen flow rate as needed to ease breathing- oxygen flow rate should not be adjusted without consulting a healthcare provider, as it can lead to complications.
C. Take antibiotic medication with or without food- The client should be advised to take the antibiotic medication as directed by the healthcare provider, which may be with or without food depending on the specific medication.
D. Decrease the steroid dose each day- It's not advisable to decrease the steroid dose each day without medical guidance.
E. Take antibiotics for 10 days- Completing the full course of antibiotics is crucial to ensure effective treatment of pneumonia and prevent recurrence or antibiotic resistance.
F. Store the oxygen cylinder wrench with the oxygen tank- storing the oxygen cylinder wrench with the oxygen tank ensures it is readily available in case of an emergency.
G. Take steroid medication in the morning- Taking steroid medication in the morning helps mimic the body's natural cortisol secretion pattern and reduces the risk of insomnia or sleep disturbances.
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