Patient Data

Exhibits

The client is seen for a 1 week follow up appointment. The nurse is evaluating the response to the treatment for cellulitis. Select the 3 findings consistent with a therapeutic response to interventions.

Temperature 98.8° F (37.1° C)

Pain 2 on a 0 to 10 scale, bilateral lower legs described as neuropathic

Serum blood glucose 185 mg/dL (10.2 mmol/L)

White blood cell count 11.2 x 103/µL (11.2 x 109/L)

Capillary refill greater than 3 seconds bilateral lower extremities

Bilateral lower extremities skin warm, dry, and pink

Answer and Explanation

Correct Answer : A,D,F

Rationale:
A. Temperature 98.8° F (37.1° C): A normal body temperature indicates resolution of the infection and a positive response to antibiotic therapy for cellulitis. Fever reduction is a key indicator of therapeutic effectiveness.

B. Pain 2 on a 0 to 10 scale, bilateral lower legs described as neuropathic: While pain is low, the description of neuropathic pain unrelated to cellulitis does not reflect improvement in the infection itself, so it is not a primary indicator of therapeutic response.

C. Serum blood glucose 185 mg/dL (10.2 mmol/L): Although improved from the initial hyperglycemia, this level is still above the normal range. It does not directly indicate resolution of cellulitis or therapeutic effectiveness of antibiotic therapy.

D. White blood cell count 11.2 x 103/µL (11.2 x 10⁹/L): The decrease toward normal limits from an elevated WBC demonstrates a positive hematologic response to treatment and reduced systemic inflammation caused by the infection.

E. Capillary refill greater than 3 seconds bilateral lower extremities: Prolonged capillary refill indicates peripheral perfusion deficits. Persistent abnormal refill is not a sign of therapeutic response and may reflect ongoing vascular compromise.

F. Bilateral lower extremities skin warm, dry, and pink: Improvement in skin color, warmth, and absence of edema or erythema reflects resolution of cellulitis and effective local tissue recovery, consistent with therapeutic response.

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Correct Answer is C

Explanation

A. Irrigate conjunctiva with ophthalmic saline prior to instilling antibiotic ointment: Routine irrigation is not typically necessary unless instructed for debris removal. Over-manipulation may increase the risk of infection or injury to the healing eye.

B. Limit exposure to sunlight during the first 2 weeks when the cornea is healing: While sunglasses can protect the eyes from UV light, strict limitation of sunlight is not usually required for 2 weeks. Standard protective measures and avoiding direct glare are sufficient.

C. Avoid straining at stool, bending, or lifting heavy objects: These activities increase intraocular pressure, which can compromise the surgical site and healing process after cataract extraction. Avoiding them is critical to prevent complications such as wound dehiscence or hemorrhage.

D. Do not read without direct lighting for 6 weeks: Reading is generally safe after cataract surgery as long as the client uses appropriate lighting. There is no standard requirement to avoid reading for 6 weeks.

A. "When did these voices begin?" B. "Have you taken any hallucinogens?" C. "Are you planning to obey the voices?" D. "Do you believe the voices are real?"

Correct Answer is C

Explanation

A. “When did these voices begin?”: While establishing the onset and history of auditory hallucinations is important for diagnosis and planning care, it does not immediately address the potential risk for harm or violence.

B. “Have you taken any hallucinogens?”: Substance use can contribute to hallucinations, but asking this first delays identifying an immediate safety risk posed by the command hallucinations.

C. “Are you planning to obey the voices?”: Command hallucinations telling someone to harm others represent a critical safety risk. Assessing the client’s intent to act on these commands is the priority to ensure safety for the client and others.

D. “Do you believe the voices are real?”: Exploring the client’s perception of reality is relevant for treatment but is secondary to assessing immediate danger associated with violent command hallucinations.

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Patient Data Exhibits The client is seen for a 1 week follow up appointment. The nurse is evaluating the response to the treatment for cellulitis. Select the 3 findings consistent with a therapeutic response to interventions.

Nursing Test Bank

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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Patient Data Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Patient Data

Exhibits

The client is seen for a 1 week follow up appointment. The nurse is evaluating the response to the treatment for cellulitis. Select the 3 findings consistent with a therapeutic response to interventions.