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A nurse is reviewing the medical record of a client

Exhibits

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

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;

Answer and Explanation

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

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is A

Explanation

A) Play music in the client's room. - Music therapy can be a beneficial nonpharmacological intervention for managing pain and promoting relaxation.
B) Keep the client's room well lit. - Bright lighting may exacerbate pain for some clients; dim lighting or allowing the client to control the lighting can be more helpful.
C) Ensure that the client's room is kept at a cool temperature. - Temperature preferences can vary among individuals; the nurse should adjust the room temperature according to the client's comfort.

D) Encourage the client to abstain from distracting activities. - Engaging in distracting activities can help divert the client's attention from pain, so encouraging them may be appropriate.

A. Recheck the client's SaO2 level after having the client cough and clear their throat. B. Notify the charge nurse of the client's condition. C. Review the client's most recent SaO2 level in the medical record. D. Check the client's medical records to see which medications were recently admitted.

Correct Answer is A

Explanation

A) Recheck the client's SaO2 level after having the client cough and clear their throat.

- This action helps determine if the low SaO2 level is due to a transient cause such as mucus or secretions blocking the airway.
B) Notify the charge nurse of the client's condition. - While important, this action should come after assessing and addressing the client's immediate needs.
C) Review the client's most recent SaO2 level in the medical record. - This information may provide context but does not address the current low SaO2 level.
D) Check the client's medical records to see which medications were recently admitted. - Medications may contribute to respiratory issues, but addressing the client's immediate respiratory distress takes priority.

View Question and Answer

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

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing nonpharmacological interventions for a client who is experiencing pain. Which of the following actions should the nurse take

Correct Answer is A

Explanation

A nurse is collecting data from a client who reports feeling short of breath and notes that the client's SpO2 level is 88% while on room air. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A nurse is reinforcing teaching about seizure management with the family of a client who has a seizure disorder. Which of the following statements by a family member indicates an understanding of the teaching?

A nurse is reviewing a client's electronic medical record (EMR). Which of the findings should the nurse identify as a risk factor for a potential accident or injury?

A nurse is reinforcing teaching about end-of-life care with the partner of a client. Which of the following statements should the nurse make?

A nurse is collecting data from a client who is 2 days postoperative following the placement of a colostomy. Which of the following findings should the nurse report to the provider?

A nurse is reinforcing teaching about advance directives with a client who has terminal colorectal cancer. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is preparing to administer a medication from an ampule. Which of the following is an appropriate action for the nurse to take?

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