After traveling to a country with a tropical climate, a young adult is diagnosed with a liver abscess and is taking antimicrobial therapy as an outpatient.
During a follow-up visit at the community clinic, the nurse observes that the patient has developed jaundice.
Which action should the nurse take?

Prepare the patient for repeat blood cultures.

Arrange emergency transport to an inpatient facility.

Explain the need to evaluate liver function.

Instruct the patient to increase protein intake.

Answer and Explanation

The Correct Answer is C

Choice A rationale

While repeat blood cultures could potentially provide useful information, they are not the immediate priority when a patient develops jaundice. Jaundice is a sign of liver dysfunction, and further evaluation of liver function is needed to determine the cause and appropriate treatment.

Choice B rationale

Arranging emergency transport to an inpatient facility may be necessary in some cases, but it is not the immediate action required in this situation. The development of jaundice indicates a need for further evaluation, but it does not necessarily indicate an emergency situation.

Choice C rationale

Explaining the need to evaluate liver function is the most appropriate action in this situation. Jaundice is a sign of liver dysfunction, and further evaluation of liver function is needed to determine the cause and appropriate treatment.

Choice D rationale

While increasing protein intake can be beneficial for some patients with liver disease, it is not the immediate priority in this situation. The development of jaundice indicates a need for further evaluation of liver function.

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

Explanation

Choice A rationale

Checking capillary refill on bilateral upper extremities can help assess peripheral circulation and identify any potential vascular injuries.

Choice B rationale

Administering morphine 2 mg IV as ordered would help manage the patient’s pain.

Choice C rationale

Performing range of motion exercises may not be appropriate immediately after the fall and before the extent of the patient’s injuries are fully assessed.

Choice D rationale

Administering ondansetron 4 mg IV as ordered can help manage any nausea or vomiting that the patient may experience, which can be a side effect of the morphine or a result of the fall itself. TemazepamTemazepam Explore

A. Measure body temperature. B. Palpate for pedal edema. C. Observe breathing patterns. D. Assess blood pressure.

Correct Answer is C,A,D,B

Explanation

Step 1: Observe breathing patterns. Respiratory depression is a critical symptom of myxedema coma that requires immediate attention.

Step 2: Measure body temperature. Hypothermia is a common symptom of myxedema coma and can provide important information about the severity of the patient’s condition.

Step 3: Assess blood pressure. Hypotension can occur in myxedema coma and can indicate the severity of the patient’s condition.

Step 4: Palpate for pedal edema. While this can be a symptom of hypothyroidism, it is not typically a primary concern in a patient showing signs of myxedema coma.

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After traveling to a country with a tropical climate, a young adult is diagnosed with a liver abscess and is taking antimicrobial therapy as an outpatient.During a follow-up visit at the community clinic, the nurse observes that the patient has developed jaundice.Which action should the nurse take?

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Naxlex Comprehensive Predictor Exams

As a nurse, you are reviewing the orders and planning initial steps for caring for the same patient.Which interventions should you perform?

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

Explanation

A patient with primary hypothyroidism is showing early signs of myxedema coma. In what order should the nurse perform the following assessments? (Rank the first action at the top with the remainder in descending order.)

Correct Answer is C,A,D,B

Explanation

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