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Exhibits

Select the 3 findings that require immediate follow-up by the nurse.

Mucus membranes

Integumentary findings

Emesis

Behavior

AST result

Vital signs

Movement of hands and fingers

Answer and Explanation

Correct Answer : B,D,F

A. Mucous membranes: Although they are noted to be dry, this alone is not an urgent finding. Mild dehydration may be monitored, especially when the client is stable and has IV access established.
B. Integumentary findings: Scratch marks and intense pruritus are consistent with cholestasis from liver dysfunction. This can lead to excoriation, infection, or indicate worsening hepatic failure, especially in the context of jaundice and elevated bilirubin.
C. Emesis: No vomiting or emesis is mentioned anywhere in the case details, making this an irrelevant and unsupported option for follow-up.
D. Behavior: The client is disoriented to time and displaying agitation with inappropriate language. In a client with alcohol use disorder and cirrhosis, this behavior can indicate the onset of hepatic encephalopathy which can rapidly progress and require immediate attention.
E. AST result: The AST level is significantly elevated (208 units/L), but liver enzymes are not immediate threats requiring urgent action. They confirm liver injury but do not direct acute intervention.
F. Vital signs: The client has a significantly elevated blood pressure (188/94 mmHg), tachycardia (120/min), and an increased temperature (38.4°C). These may reflect an acute withdrawal syndrome, sepsis, or intracranial injury—all of which demand urgent follow-up.
G. Movement of hands and fingers: There is no indication of tremors, asterixis, or motor deficits in the notes. Therefore, hand and finger movement does not currently present as a priority concern.

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Free Nursing Study Resources

Correct Answer is D

Explanation

A. “The proxy should manage legal issues for the client.”: Legal matters are typically handled by a general power of attorney, not a durable power of attorney for health care. The health care proxy is specifically responsible for making medical decisions, not legal ones.
B. “The proxy can make financial decisions if the need arises.”: Financial decisions fall under the responsibilities of a financial power of attorney, not a health care proxy. The DPAHC is limited to health-related decisions when the client is unable to do so.
C. "The proxy should make health care decisions for the client regardless of the client's ability to do so.": The health care proxy only assumes decision-making authority when the client is no longer capable of making or communicating their own medical decisions.
D. "The proxy can make treatment decisions if the client is under anesthesia.": A DPAHC authorizes the health care proxy to make medical decisions when the client is temporarily or permanently incapacitated, including during periods such as surgery under anesthesia.

A. A B. B C. C D. D

Correct Answer is A

Explanation

Using proper body mechanics is vital to prevent injury and ensure safe lifting. Key principles include keeping the back straight and neutral to reduce spinal stress and bending at the knees and hips to engage stronger leg muscles rather than the lower back. Maintaining a shoulder-width stance provides stability, while holding objects close to the body decreases spinal strain. Lifting with the legs, not the back, further protects the spine. Twisting should be avoided—pivoting with the feet maintains alignment and reduces injury risk. Keeping the head and neck aligned with the spine improves posture and visual focus. Using smooth, controlled movements prevents muscle strain and dropped objects. Assessing an object’s weight before lifting helps determine if help or equipment is needed, preventing overexertion. Supportive footwear with a good grip ensures balance and minimizes fall risk. These ergonomic practices promote safety, reduce injuries, and are essential in both clinical and everyday environments.

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Exhibits Select the 3 findings that require immediate follow-up by the nurse.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse is teaching a newly licensed nurse about clients designating a health care proxy in situations that require a durable power of attorney for health care (DPAHC). Which of the following information should the charge nurse include?

Correct Answer is D

Explanation

A staff education nurse is evaluating a group of nurses during a new employee orientation on the use of proper body mechanics when lifting. Which of the following images indicates the appropriate use of ergonomic principles? A. B. C. D.

Correct Answer is A

Explanation

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Exhibits

Select the 3 findings that require immediate follow-up by the nurse.