Exhibits
Which information from the history and physical, nurses' note, and flow sheet requires further evaluation? Select all that apply.
Occupation of legal secretary
Stiffness in hands for 3 months
Radial and pedal pulses 2+
Pain in bilateral hands and wrists
History of asthma using albuterol inhaler PRN
Capillary refill 2 seconds
Body mass index (BMI) of 31 kg/m2
Client's hobbies
Correct Answer : A,B,D,G,H
A. Occupation of legal secretary: The client works as a legal secretary, which may involve extensive typing or repetitive hand movements. This can contribute to musculoskeletal stress or strain, potentially exacerbating symptoms like pain and stiffness in the hands.
B. Stiffness in hands for 3 months: The client reports stiffness in both hands and wrists for the past 3 months, which could suggest an inflammatory arthritis such as rheumatoid arthritis (RA). This warrants further evaluation, especially given her family history of arthritis.
C. Radial and pedal pulses 2+: A rating of 2+ for radial and pedal pulses is normal, indicating no circulation issues, and does not need further evaluation.
D. Pain in bilateral hands and wrists: Persistent, symmetrical pain in the hands and wrists, particularly with palpation, may indicate a condition like rheumatoid arthritis. This symptom, in combination with morning stiffness, needs further investigation.
E. History of asthma using albuterol inhaler PRN: The client's history of well-controlled asthma, managed with an albuterol inhaler as needed for exacerbations, does not directly relate to her current presentation of hand pain and stiffness.
F. Capillary refill 2 seconds: A capillary refill time of 2 seconds is within the normal range, indicating adequate peripheral perfusion. This finding suggests that there are no immediate circulatory issues contributing to her hand pain and stiffness and does not require further evaluation.
G. Body mass index (BMI) of 31 kg/m²: A BMI of 31 falls within the obese range, which can increase the risk for musculoskeletal issues and other chronic conditions. This factor should be evaluated further, as obesity may affect joint health.
H. Client's hobbies: The client enjoys hobbies like gardening and crocheting, which involve repetitive hand movements. These activities could exacerbate the pain and stiffness in her hands, making it important to evaluate whether these hobbies are contributing to her symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E","G","H"]
Explanation
A. Temperature 99.9° F (37.7° C): A mild fever (99.9°F) is not a direct indicator of dehydration but could be related to other factors, including the body’s response to stress. It is not an immediate priority compared to other signs like poor skin turgor or low blood pressure.
B. Respirations 34 breaths/minute: An elevated respiratory rate may occur with dehydration, but it is not specific to dehydration alone. It should be monitored, especially when combined with other symptoms, but it is not a sole indicator of dehydration.
C. Heart rate 136 beats/minute: A heart rate of 136 beats per minute is elevated and may indicate dehydration, as the body attempts to compensate for reduced blood volume. Tachycardia is a common response to fluid loss and requires immediate follow-up.
D. Weak peripheral pulses: Weak peripheral pulses reflect poor circulation, which can be a result of dehydration. This finding indicates decreased perfusion and demands urgent attention to restore fluid balance and ensure proper circulation.
E. Dry mucous membranes: Dry mucous membranes are a hallmark sign of dehydration, as the body reduces fluid availability for non-essential processes. This finding should be immediately addressed, as it is a clear sign of fluid loss.
F. Body mass index (BMI) 21.9 kg/m²: BMI is a general indicator of body weight and is not related to fluid balance. While it provides useful information about the client’s overall health, it does not directly point to dehydration or fluid loss.
G. Blood pressure 100/52 mm Hg: Low blood pressure, especially in the context of dehydration, is a significant concern. A blood pressure of 100/52 mm Hg is a sign of hypovolemia or fluid loss, and immediate intervention is needed to restore normal fluid volume and prevent shock.
H. Poor skin turgor: Poor skin turgor is a classic sign of dehydration, where the skin remains tented after being pinched. This indicates a lack of sufficient fluid in the body, which must be addressed immediately to prevent further complications.
Correct Answer is ["A","D","E"]
Explanation
A. Ask the client if she has any alcohol in the room at this time: This is an essential step in assessing for immediate safety and contraband that may impact her treatment plan, especially considering her symptoms and possible withdrawal risk.
B. Administer a PRN prescription for an antianxiety drug: This could mask symptoms of alcohol withdrawal or interact negatively with alcohol. Medication should be given only after thorough assessment and consultation.
C. Inform the family that they are enabling the client: While family education is important, using accusatory language like "enabling" can damage therapeutic relationships. A nonjudgmental, supportive approach is better.
D. Observe for signs to determine if client is inebriated: Monitoring for inebriation supports accurate clinical assessment and decisions about withdrawal protocols, safety, and medication timing.
E. Schedule a conference with the client and family members: A joint meeting allows open discussion, identifies care goals, and promotes understanding and support from all parties involved.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.