A nurse is reviewing the medical record of a client. Which of the following findings should the nurse report to the provider?

These are the medical report: Abdomen soft, no palpable mass, bowel sounds heard.

Temperature 97.7°F, Urine specific gravity 1.035, albumin 4.5 mg/L, prealbumin 25 mg/dL and potassium 4.2 mg/dL

Urine specific gravity

Prealbumin

Temperature

Bowel sounds

Answer and Explanation

The Correct Answer is A

Choice A reason:

Urine specific gravity is the measurement of the concentration of solutes in urine and is an important indicator of the client's hydration status and kidney function. A specific gravity of 1.035 is relatively high, suggesting concentrated urine. High urine specific gravity can be a sign of dehydration or other kidney-related issues.

Reporting this finding to the provider is crucial because it could indicate potential problems with the client's fluid balance and kidney function. The provider may need to assess further, conduct additional tests, or initiate appropriate interventions to address the client's hydration and renal status.

Choice B reason:

Prealbumin: A prealbumin level of 25 mg/dL is within the normal range (usually 15-35 mg/dL) and may not require immediate reporting to the provider. Prealbumin is used to assess nutritional status, and this result suggests that the client's nutritional status is within the normal range.

Choice C reason:

Temperature: The normal range is 36.5°-37.5°C (97.7°-99.5°F),thus it falls within normal range.

Choice D reason

Bowel sounds: Bowel sounds: Bowel sounds heard is a normal finding and indicates normal gastrointestinal function.

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Free Nursing Study Resources

Correct Answer is ["C","D","E"]

Explanation

A.The client's weight has remained relatively stable (83.9 kg to 83 kg), which does not indicate an immediate health concern compared to the acute behavioral and mental health symptoms observed.

B. While the client's neurostatus (mental status) is affected by the presence of auditory hallucinations, pressured speech, and restlessness, these symptoms are more critical in terms of immediate management than a general assessment of neurologic status.

C. Auditory hallucinations, such as appearing to listen to unseen others, are concerning symptoms indicating possible exacerbation of schizophrenia or medication non-compliance. Immediate assessment and intervention by mental health professionals are needed.

D.Pressured speechis commonly seen in mania or anxiety.Poverty of speechcan be associated with shyness, depression, schizophrenia, or cognitive impairment. Pressured speech noted along with other symptoms can indicate agitation or worsening of mental health symptoms. It suggests the client may be experiencing an acute phase of their illness, requiring evaluation and possibly adjustment of medications.

E. Restlessness, frequently getting out of the chair, and appearing tired and disheveled indicate agitation and potential agitation or anxiety. This could be a sign of increased agitation, anxiety, or distress, which needs immediate attention to prevent escalation.

A. The client is taking numerous deep, measured breaths. B. The client is calmly telling their partner that "the staff here is so controlling." C. The client is sitting with their head in their hands and appears to be crying. D. The client is pacing around the chair in which their partner is sitting.

Correct Answer is D

Explanation

A. The client is taking numerous deep, measured breaths. This is not an indication of potential violence, but rather a coping strategy to calm down and regulate emotions.

B. The client is calmly telling their partner that "the staff here is so controlling." This is not an indication of potential violence, but rather a expression of frustration or dissatisfaction with the treatment setting.

C. The client is sitting with their head in their hands and appears to be crying. This is not an indication of potential violence, but rather a sign of sadness or distress.

D. The client is pacing around the chair in which their partner is sitting. This is an indication of potential violence, as it shows restlessness, agitation, and possible intimidation of the partner.

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Naxlex Comprehensive Predictor Exams

Correct Answer is ["C","D","E"]

Explanation

A nurse on an inpatient mental health unit is monitoring a visit between a client who has a history of aggressive behavior and the client's partner. Which of the following observations should the nurse identify as an indication for potential violence?

Correct Answer is D

Explanation

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