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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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Correct Answer is C

Explanation

A. A client who is confused, is febrile, and has foul-smelling urine: These symptoms suggest a urinary tract infection potentially progressing to sepsis, which is serious but does not take priority over signs of possible stroke or brain injury.
B. A client who has sickle cell disease and reports severe joint pain: Severe pain is expected in sickle cell crises and requires prompt management, but it is not as time-sensitive as neurologic deterioration.
C. A client who has slurred speech, is disoriented, and reports a headache: These findings suggest a possible stroke or other neurological emergency such as a brain hemorrhage or increased intracranial pressure, which requires immediate evaluation and intervention.
D. A client who has a dislocated left shoulder: Although painful and requiring attention, a shoulder dislocation is not immediately life-threatening and does not take precedence over potential neurologic compromise.

A. Review the child's electronic pain diary. B. Request a change in medication from the provider, C. Set up an appointment with the school nurse. D. Refer the family to a chronic pain support group.

Correct Answer is A

Explanation

A. Review the child's electronic pain diary: This should be the first action as it provides valuable information about the frequency, triggers, duration, and severity of the headaches. It helps the nurse and provider make informed decisions about treatment and next steps.
B. Request a change in medication from the provider: Medication changes should be based on a thorough assessment of the child’s headache pattern and response to current therapy, which starts with reviewing documented data.
C. Set up an appointment with the school nurse: While coordination with the school is important for managing chronic conditions, it is not the priority action before understanding the nature and pattern of the headaches.
D. Refer the family to a chronic pain support group: Support groups are helpful in long-term management, but should follow a thorough assessment and diagnosis of the child’s condition and needs.

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

Nursing Test Bank

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Exhibits

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