How it Works
Try Naxlex NCLEX-RN (Free-Trial)

Exhibits
A nurse is reviewing the medical record of a client who has schizophrenia. Which of the following findings should the nurse report to the provider? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data.)

A.

Dietary intake

B.

Sore throat

C.

Heart rate

D.

Blood pressure

Answer and Explanation

The Correct Answer is B

Rationale:

A. Dietary intake: The client ate 75% of breakfast, which indicates adequate oral intake. While monitoring nutrition is important in schizophrenia, this finding does not pose an immediate safety concern or require urgent reporting.

B. Sore throat: A sore throat in a client taking clozapine is significant because clozapine can cause agranulocytosis, a potentially life-threatening reduction in white blood cells. Any signs of infection, such as sore throat or fever, must be reported immediately to prevent serious complications.

C. Heart rate: A heart rate of 98/min is slightly elevated but within acceptable limits for many adults. This finding alone does not indicate an urgent issue requiring immediate provider notification.

D. Blood pressure: A blood pressure of 102/56 mm Hg is slightly low but may be within the client’s normal range, particularly if the client experiences dizziness when changing positions. While it should be monitored, it does not require urgent reporting unless symptoms worsen.


Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is D,C,A,B

Explanation

D. Rolling from back to side is the earliest movement and reflects initial development of trunk rotation and muscle control. This typically occurs around 4 months of age. C. Rolling from back to abdomen requires greater coordination and strength than rolling to the side and usually occurs around 5 to 6 months as infants gain better control of their core muscles. A. Sitting steadily unsupported develops once the infant has strong trunk control and balance, typically around 6 to 8 months. This skill indicates improved postural stability. B. Changing from prone to sitting is the most advanced skill listed. It requires coordinated use of the arms, core, and balance, and typically occurs later around 8 to 10 months as mobility becomes more purposeful.

Correct Answer is B

Explanation

Rationale:

A. Shoulders: The shoulders are usually covered with clothing and have more pigmentation and subcutaneous tissue, making color changes less apparent. Cyanosis may be difficult to detect in these areas, especially in clients with dark skin.

B. Palms of the hands: The palms, along with the soles of the feet, nail beds, and mucous membranes, have less melanin and are more reliable sites to observe for cyanosis in clients with dark skin. These areas can show a bluish or grayish discoloration more accurately when oxygenation is low.

C. Area of trauma: Trauma sites may exhibit bruising, erythema, or inflammation, which can mask the presence of cyanosis. Assessing these areas may lead to inaccurate conclusions regarding oxygenation status.

D. Sacrum: While the sacrum may be assessed for pressure injuries, it is not a reliable site for detecting cyanosis because of pigmentation, limited blood flow, and potential masking by subcutaneous tissue. The nurse should focus on areas with minimal pigmentation for accurate assessment.

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Register