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 ["B","C","E"]
Explanation
A) A client reports being dissatisfied with the temperature of the meals provided. - This situation does not pose a risk to the client's safety or result in harm, so an incident report is not necessary.
B) A client receives burns from a heating pad. - Any incident resulting in harm to the client, such as burns from a heating pad, should be documented with an incident report.
C) A client becomes disoriented and falls out of bed. - Falls resulting in injury or disorientation require documentation via an incident report.
D) A client is unable to afford the physical therapy that the provider recommends. - Financial constraints do not necessitate an incident report.
E) A client's visitor becomes dizzy and faints in the client's room. - Incidents involving visitors, especially if they occur in the client's presence, should be documented with an incident report.
Correct Answer is B
Explanation
A. "I will gently restrain him during seizures."- Restraint during seizures can cause injury and is not recommended.
B. "I will loosen his clothing during seizures."- Loosening tight clothing helps prevent injury and ensures adequate ventilation during a seizure.
C. "I will insert a washcloth in his mouth during seizures."- Inserting objects into the mouth during a seizure can cause injury or obstruct the airway.
D. "I will turn him on his back during seizures."- Placing the client on their back during a seizure can increase the risk of aspiration. The recovery position is preferred
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