A nurse on a step-down unit is admitting a client.
Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again
Nurses' Notes
Day 3, 1350:
Client transferred to step-down unit from ICU for continued care following a myocardial infarction (MI) 2 days ago. Oriented to room. Client reports a productive cough, States they are short of breathand that ambulating to the bathroom has resulted in chest pain. Reports pain as 3 on a scale of 0 to 10. Client appears anxious and reports a fear of dying.
Oriented to room.
Client reports a productive cough
States they are short of breathand that ambulating to the bathroom has resulted in chest pain.
Reports pain as 3 on a scale of 0 to 10.
Client appears anxious and reports a fear of dying.
The Correct Answer is ["B","C","E"]
Rationale for Correct Findings:
- Productive cough: In a client with COPD and recent MI, this may signal infection or fluid overload, especially if paired with fever, dyspnea, and hypoxia. Immediate assessment is needed to rule out pneumonia or heart failure.
- Shortness of breath and chest pain with ambulation: This raises concern for myocardial ischemia, reinfarction, or worsening heart function. Chest pain with minimal exertion post-MI demands prompt evaluation and possible ECG and oxygen therapy.
- Anxiety and fear of dying: Sudden intense fear may indicate worsening hypoxia, cardiac distress, or even be a prodrome to another MI. It should not be dismissed as purely psychological, especially in the context of other concerning symptoms.
Rationale for Incorrect Findings:
- Pain rated 3/10: A mild pain score suggests the discomfort is currently manageable. While chest pain after MI is always important, this level does not in itself indicate an emergency unless it worsens or is unrelieved.
- Oriented to room: Being alert and oriented indicates preserved cognition and neurologic stability. No immediate follow-up is needed based on this observation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}
Explanation
Rationale for Correct Choices:
- Endometritis: Endometritis is a common postpartum infection of the uterine lining, often following cesarean birth, especially with risk factors like prolonged rupture of membranes and anemia. Clinical features include uterine tenderness, foul-smelling lochia, and fever, all of which are present in this case.
- Uterus and lochia assessment: A uterus that is tender and slightly elevated, with moderate dark brown, malodorous lochia, is a hallmark of endometritis. The boggy fundus that firms with massage also suggests poor involution, frequently associated with infection.
Rationale for Incorrect Choices:
- Mastitis: While the client reports breast discomfort, mastitis typically presents with unilateral breast pain, localized redness, and flu-like symptoms. The findings here are more consistent with engorgement than with infectious mastitis.
- Pneumonia: The client has no respiratory distress, productive cough, or abnormal lung sounds (only slightly diminished bases), and oxygen saturation is normal. These signs are insufficient to support pneumonia.
- Fever: Although fever is present (38.2°C), it is a nonspecific symptom that could occur with any postpartum infection or inflammation. It supports infection but does not localize the source as definitively as the uterine and lochia findings.
- WBC count: The elevated WBC count (33,000/mm³) indicates infection or inflammation, but again, it is nonspecific. It supports the diagnosis but does not point solely to endometritis without clinical context from the uterus and lochia.
Correct Answer is A,B,C,D
Explanation
Rationale:
A. Rolls from back to side: This is typically the first gross motor milestone among the listed options and usually occurs around 4 months of age. It marks early trunk and upper body control development.
B. Rolls from back to abdomen: Rolling from back to abdomen requires more strength and coordination and generally occurs around 5 to 6 months of age, following the ability to roll to the side.
C. Sits steadily unsupported: Infants begin sitting without support around 7 to 8 months, once they develop adequate trunk and head control. This milestone represents a major progression in balance and posture.
D. Changes from prone to sitting: Transitioning from a prone to a sitting position typically develops around 9 to 10 months. It involves coordinated control of the arms, trunk, and legs and reflects advanced gross motor skill development.
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