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A nurse on a medical surgical unit is admitting a client from a provider's office.

Exhibits
Click to highlight the information in the Nurse's Notes and Vital Signs that should be reported to the provider.

1500:                         

  • Temperature: 39 degrees Celcius (102.2 F)
  • Heart rate: 122/min
  • Respiratory rate: 24/min
  • BP: 106/54 mmHg
  • Oxygen saturation: 95% on room air

1530:

  • Client lethargic, reporting abdominal cramping, experiencing projectile vomiting.
  • Voiding dark, concentrated urine.
  • Client requesting water

A.

Temperature: 39 degrees Celcius (102.2 F)

B.

Heart rate: 122/min

C.

Respiratory rate: 24/min

D.

BP: 106/54 mmHg

E.

Oxygen saturation: 95% on room air

F.

Client lethargic, reporting abdominal cramping, experiencing projectile vomiting.

G.

Voiding dark, concentrated urine.

H.

Client requesting water

Answer and Explanation

The Correct Answer is ["A","B","D","F","G","H"]

Vital Signs

  • Temperature: 39°C (102.2°F) → fever worsened since admission (sign of possible infection).
     
  • Heart rate: 122/min → tachycardia, worsened compared to earlier.
     
  • Blood pressure: 106/54 mmHg → trending downward, may indicate fluid deficit/hypotension risk.

Nurse’s Notes

  • Client lethargic → worsening mental status.
     
  • Projectile vomiting → new onset, risk of dehydration and electrolyte imbalance.
     
  • Abdominal cramping → possible gastrointestinal complication.
     
  • Voiding dark, concentrated urine → sign of dehydration.
     
  • Client requesting water → excessive thirst consistent with hyperglycemia/possible hyperosmolar state.


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Related Questions

Correct Answer is ["A","B","D","F","G","H"]

Explanation

Vital Signs

  • Temperature: 39°C (102.2°F) → fever worsened since admission (sign of possible infection).
  • Heart rate: 122/min → tachycardia, worsened compared to earlier.
  • Blood pressure: 106/54 mmHg → trending downward, may indicate fluid deficit/hypotension risk.

Nurse’s Notes

  • Client lethargic → worsening mental status.
  • Projectile vomiting → new onset, risk of dehydration and electrolyte imbalance.
  • Abdominal cramping → possible gastrointestinal complication.
  • Voiding dark, concentrated urine → sign of dehydration.
  • Client requesting water → excessive thirst consistent with hyperglycemia/possible hyperosmolar state.

Correct Answer is ["A","B","C"]

Explanation

Rationale:

A. Decompensated cirrhosis impairs the liver’s ability to process bilirubin, leading to yellowing of the skin and eyes.

B. Accumulation of ammonia and other toxins due to liver dysfunction can cause confusion, altered level of consciousness, and asterixis.

C. Fluid shifts into the peritoneal cavity occur due to low albumin levels and portal hypertension, causing abdominal distention.

D. While beneficial for overall health, exercise is not a clinical manifestation of cirrhosis.

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