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A nurse on a step-down unit is admitting a client.


Exhibits

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.
 

A.

Oriented to room.

B.

Client reports a productive cough

C.

States they are short of breathand that ambulating to the bathroom has resulted in chest pain.

D.

Reports pain as 3 on a scale of 0 to 10.

E.

Client appears anxious and reports a fear of dying.

Answer and Explanation

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.


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Related Questions

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.

Correct Answer is C

Explanation

Rationale:

A. Gelatin: Gelatin allergies are more relevant when assessing for risk with certain vaccines like MMR or varicella, which may contain gelatin as a stabilizer. It is not a primary concern with most influenza vaccines.

B. Shellfish: Shellfish allergies are associated with reactions to iodine-based contrast, not vaccines. They do not impact the safety of receiving the influenza vaccine.

C. Egg: Many influenza vaccines are manufactured using egg-based processes, which can leave residual egg protein. Although most clients with egg allergies can now safely receive the vaccine, this allergy is still important to assess before administration.

D. Milk: Milk allergies are not linked to influenza vaccines and do not affect vaccine safety. There is no milk protein used in the manufacturing of flu vaccines.

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