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Patient data

Exhibits

The nurse considers the brief interaction with the client and the triage report.
Which finding(s) should the nurse investigate further? Select all that apply.

Left arm that is cool to touch

Decreased range of motion

Swelling at the site of injury

Intense pain reported by client

Oxygen saturation 95% on room air

Blood pressure of 136/90 mm Hg

Nausea and fatigue reported by client

Bone misalignment

Answer and Explanation

Correct Answer : A,B,D,G,H

A. Left arm that is cool to touch: A cool extremity can indicate impaired circulation, which is a priority concern after trauma. It may suggest compromised perfusion or neurovascular compromise, requiring immediate further investigation.

B. Decreased range of motion: The inability to move the left arm signals possible fracture, dislocation, or neurovascular impairment. Limited mobility after trauma should always be investigated to determine the extent of musculoskeletal injury.

C. Swelling at the site of injury: Swelling is expected following trauma and does not necessarily indicate a complication. While it should be monitored, it is not as urgent to investigate further compared with circulation or alignment changes.

D. Intense pain reported by client: Severe, constant pain out of proportion to the injury raises concern for complications such as compartment syndrome, fracture, or vascular compromise. This finding requires prompt further assessment and intervention.

E. Oxygen saturation 95% on room air: Although slightly lower than ideal, this level is still acceptable in an older adult and not immediately alarming. It does not require urgent further investigation compared to other more critical findings.

F. Blood pressure of 136/90 mm Hg: This blood pressure indicates mild hypertension but is not an acute concern in the setting of trauma. It does not require urgent investigation at this point.

G. Nausea and fatigue reported by client: These symptoms may suggest a head injury, concussion, or internal response to trauma. Given the reported head impact, these findings warrant further neurological evaluation.

H. Bone misalignment: Visible misalignment strongly suggests fracture or dislocation. This finding must be investigated further to confirm the diagnosis and prevent neurovascular complications.

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Correct Answer is D

Explanation

A. Administer intravenous antibiotic: Antibiotics are often given as part of appendicitis management, but sudden pain relief may indicate appendix rupture. At this point, the priority is rapid surgical intervention, not antibiotics alone.

B. Place in high Fowler's position: Positioning may help with comfort but does not address the urgent complication of a possible perforated appendix. It is a supportive measure, not a definitive response to the change in symptoms.

C. Determine last dose of analgesic: While it is important to know when pain medication was last administered, relying on this alone could delay recognition of a surgical emergency. Sudden absence of pain in appendicitis is rarely due to analgesia but often due to perforation.

D. Prepare for emergency surgery: A sudden decrease in pain in appendicitis is concerning for rupture, as pressure is relieved when the appendix bursts. This is a life-threatening complication requiring immediate surgical evaluation and intervention.

A. Risk for fluid and electrolyte imbalance. B. Disturbed body image related to loss of control. C. Imbalanced nutrition less than body requirements. D. Impaired coping related to excessive physical activity.

Correct Answer is C

Explanation

A. Risk for fluid and electrolyte imbalance: While important, this risk is secondary to the immediate physiological consequences of insufficient nutrition. Electrolyte imbalances often develop as a result of malnutrition and require close monitoring.

B. Disturbed body image related to loss of control: Body image disturbance is central to anorexia nervosa, but it does not pose an immediate threat to life. Psychological interventions are essential but follow stabilization of physical health.

C. Imbalanced nutrition less than body requirements: Inadequate nutrition directly threatens physiological stability, affecting cardiovascular, gastrointestinal, and endocrine function. Restoring adequate nutrition is the highest priority to prevent life-threatening complications such as organ failure or severe electrolyte disturbances.

D. Impaired coping related to excessive physical activity: Excessive exercise may worsen malnutrition and stress, but it is secondary to the urgent need to correct nutritional deficits and stabilize the client’s physical condition.

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Patient data Exhibits The nurse considers the brief interaction with the client and the triage report. Which finding(s) should the nurse investigate further? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client admitted with a diagnosis of appendicitis calls the nurse and states, "Do you think I'll still need surgery? My pain suddenly stopped, and I feel much more comfortable now when I bend my knees." Which action should the nurse take?

Correct Answer is D

Explanation

The nurse is caring for a client with anorexia nervosa who states, "I feel powerless when I gain weight." Which problem should the nurse identify as a priority?

Correct Answer is C

Explanation

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Patient data

Exhibits

The nurse considers the brief interaction with the client and the triage report.
Which finding(s) should the nurse investigate further? Select all that apply.