Exhibits
The nurse is reviewing the client's medical record. Select the four findings that require immediate follow-up:
Blood glucose level
Bowel sounds
Blood pressure
Pain level
Electrocardiogram findings
Lung sounds
Troponin T level
Correct Answer : C,D,E,G
C. The blood pressure readings show significant variability (164/80 mm Hg at 1000, 176/82 mm Hg at 1015, and 110/62 mm Hg at 1200). These fluctuations, especially the higher readings, indicate potential instability and require close monitoring and possibly intervention.
D. The client's pain level is described as 7/10 initially (1000) and decreases to 5/10 after nitroglycerin (1200). Although the pain has decreased, ongoing assessment is necessary to ensure it does not worsen or change in nature.
E. The 12-lead electrocardiogram (ECG) shows tachycardia with ST segment elevation and T wave changes, which are indicative of myocardial ischemia or infarction. This finding requires immediate attention as it suggests ongoing cardiac damage.
G. The troponin T level is elevated at 0.40 ng/mL (normal is less than 0.1 ng/mL). Troponin elevation indicates myocardial injury or infarction and confirms the seriousness of the cardiac event. This finding requires immediate attention to assess the extent of myocardial damage and guide further treatment.
Incorrect Choices
A. While it is slightly elevated, it is not significantly outside the normal range and does not suggest immediate danger or require urgent intervention in the context of the acute cardiac issue. However, monitoring blood glucose levels is important for overall management, especially in a client with diabetes mellitus.
B. The assessment of bowel sounds being present in all 4 quadrants is a normal finding and indicates normal gastrointestinal function. While bowel sounds are important for assessing gastrointestinal health, they are not immediately pertinent to the acute cardiac issue described in the scenario.
F. The nurse notes that lung sounds are clear to auscultation in all lobes, which is a normal finding. Clear lung sounds suggest normal respiratory function and do not require immediate attention in the context of the acute cardiac event described.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Nuchal rigidity refers to stiffness or resistance to neck movement, especially when the client's head is flexed forward. It is a classic sign of meningitis due to irritation and inflammation of the meninges (the membranes surrounding the brain and spinal cord). This assessment helps to detect meningeal irritation, a hallmark of meningitis.
B. This action tests the deep tendon reflex, specifically the knee jerk reflex (patellar reflex). It assesses the integrity of the spinal cord and peripheral nerves. While it is part of a neurological assessment, it is not specifically related to the assessment of meningitis unless there are concurrent neurological symptoms or signs.
C This maneuver tests for Babinski reflex, which is an abnormal response where the toes flare upward and the big toe dorsiflexes when the sole of the foot is stimulated. A positive Babinski reflex can indicate dysfunction of the corticospinal tract or brain injury but is not a specific finding in meningitis.
D. Tapping the facial nerve (cranial nerve VII) assesses for the presence of facial nerve irritation or damage. In the context of meningitis, signs such as facial twitching or asymmetry may indicate involvement of cranial nerves due to inflammation and pressure within the skull.
Correct Answer is C
Explanation
C. During an asthma attack, the airways narrow, making it difficult to exhale. This traps air in the lungs, including carbon dioxide.
A This might be true for someone with poorly controlled asthma, but during an acute attack, the airways are already hypersensitive and constricted in response to triggers.
B. This is the opposite of what happens in asthma. Asthma is characterized by inflammation in the airways.
D. Alveolar elasticity refers to the ability of the air sacs in the lungs to recoil after being inflated. While this can be a problem in some lung diseases, it's not the primary issue in an acute asthma attack.
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