Exhibits

The triage nurse does a rapid assessment of the client. Which data indicates the client is in need of immediate health interventions?

The client's age

The client's facial droop

The client's garbled speech

The client's alcohol consumption

The client's seafood intake

Answer and Explanation

The Correct Answer is B

a) The client's age: The client is 70 years old, which puts her at a higher risk of having a stroke or other cardiovascular problems. Stroke is a medical emergency that requires prompt treatment to prevent brain damage and disability.

b) The client's facial droop: The client has a noticeable facial droop, which is a sign of facial nerve weakness or paralysis. This can be caused by a stroke, Bell's palsy, or other neurological conditions. Facial droop can affect the client's ability to speak, eat, and express emotions.

c) The client's garbled speech: The client has garbled speech, which means she has difficulty producing or understanding words. This can be caused by a stroke, brain injury, or other disorders that affect the language areas of the brain. Garbled speech can impair the client's communication and cognition.

d) The client's alcohol consumption: The client had a few drinks at a seafood restaurant, which may have interacted with her medications or medical conditions. Alcohol can increase the risk of bleeding, lower blood pressure, and worsen dehydration. Alcohol can also impair the client's judgment and coordination.

e) The client's seafood intake: The client ate seafood at a restaurant, which may have triggered an allergic reaction or food poisoning. Seafood allergies can cause symptoms such as hives, swelling, breathing difficulties, and anaphylaxis. Food poisoning can cause symptoms such as nausea, vomiting, diarrhea, and dehydration.

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Correct Answer is C

Explanation

Choice A reason: Potassium 4.7 mEq/L (4.70 mmol/L) is within the normal reference range of 3.5 to 5 mEq/L (3.5 to 5 mmol/L). Potassium is an electrolyte that helps regulate the balance of fluids and acids in the body, as well as the function of nerves and muscles. A high potassium level (hyperkalemia) can cause muscle weakness, irregular heartbeat, and cardiac arrest. A low potassium level (hypokalemia) can cause muscle cramps, fatigue, and arrhythmias.

Choice B reason: Magnesium 2.1 mEq/L (0.86 mmol/L) is within the normal reference range of 1.3 to 2.1 mEq/L (0.65 to 1.05 mmol/L). Magnesium is an electrolyte that helps regulate the activity of enzymes, muscles, and nerves, as well as the balance of calcium and potassium in the body. A high magnesium level (hypermagnesemia) can cause nausea, vomiting, flushing, muscle weakness, and respiratory depression. A low magnesium level (hypomagnesemia) can cause muscle twitching, tremors, seizures, and cardiac arrhythmias.

Choice C reason: Calcium 6.5 mg/dL (1.63 mmol/L) is below the normal reference range of 9 to 10.5 mg/dL (2.3 to 2.6 mmol/L). Calcium is an electrolyte that helps regulate the function of muscles, nerves, bones, and blood clotting. A high calcium level (hypercalcemia) can cause nausea, vomiting, constipation, confusion, kidney stones, and bone pain. A low calcium level (hypocalcemia) can cause muscle spasms, cramps, tingling, numbness, and stridor (a high-pitched sound when breathing). **This is a critical value that should be immediately reported to the healthcare provider**, as it can indicate a serious condition such as acute pancreatitis, sepsis, or massive blood transfusion.

Choice D reason: Sodium 135 mEq/L (135 mmol/L) is slightly below the normal reference range of 136 to 145 mEq/L (136 to 145 mmol/L). Sodium is an electrolyte that helps regulate the balance of fluids and acids in the body, as well as the function of nerves and muscles. A high sodium level (hypernatremia) can cause thirst, dry mouth, confusion, seizures, and coma. A low sodium level (hyponatremia) can cause headache, nausea, vomiting, fatigue, muscle weakness, and confusion.

A. Consume a high protein diet. B. Obtain a prostate-specific antigen blood level test. C. Take vitamin supplements. D. Increase physical activity.

Correct Answer is D

Explanation

Choice A reason: This is incorrect because consuming a high protein diet is not a recommended strategy to reduce risk factors for BPH. In fact, some studies have suggested that a high protein intake may increase the risk of BPH by stimulating the production of insulin-like growth factor-1 (IGF-1), which may promote prostate growth.

Choice B reason: This is incorrect because obtaining a prostate-specific antigen blood level test is not a preventive measure for BPH, but rather a diagnostic tool to detect prostate cancer or monitor its treatment. Prostate-specific antigen (PSA) is a protein produced by the prostate gland that can be elevated in both BPH and prostate cancer. However, PSA levels alone cannot distinguish between these two conditions and need to be interpreted along with other factors, such as age, race, family history, and digital rectal examination.

Choice C reason: This is incorrect because taking vitamin supplements is not a proven method to reduce risk factors for BPH. While some vitamins, such as vitamin D and vitamin E, may have some beneficial effects on prostate health, there is not enough evidence to support their use as preventive agents for BPH. Moreover, some vitamins, such as vitamin A and vitamin B6, may have adverse effects on prostate health and increase the risk of BPH or prostate cancer.

Choice D reason: This is correct because increasing physical activity is a helpful way to reduce risk factors for BPH. Physical activity can help maintain a healthy weight, lower blood pressure, improve blood circulation, reduce inflammation, and regulate hormone levels. All of these factors can contribute to preventing or delaying the development of BPH.

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Exhibits The triage nurse does a rapid assessment of the client. Which data indicates the client is in need of immediate health interventions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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Exhibits

The triage nurse does a rapid assessment of the client. Which data indicates the client is in need of immediate health interventions?