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Patient Data

Exhibits

The nurse is reviewing the client's initial assessment findings.
Which assessment findings require follow-up? Select all that apply.

IV site without redness or swelling

Temperature: 98.8° F (37.1° C)

Respirations: 28 breaths/minute

Heart rate: 92 beats/minute

Taking shallow breaths

Alert and oriented to person, place, time and situation

Pain 8 on a 0 to 10 scale

Blood pressure: 138/82 mm Hg

Answer and Explanation

Correct Answer : C,E,G

A. IV site without redness or swelling: The IV site appears normal with no signs of infiltration or infection, so no immediate follow-up is required. This finding indicates proper IV insertion and maintenance.

B. Temperature: 98.8° F (37.1° C): This is within normal limits and does not indicate fever or infection, so it does not require immediate follow-up.

C. Respirations: 28 breaths/minute: This is above the normal adult range (12–20 breaths/minute) and may indicate respiratory distress due to pain, shallow breathing, or possible pulmonary complications such as atelectasis or pneumonia, requiring close monitoring and follow-up.

D. Heart rate: 92 beats/minute: Slightly elevated but within mild tachycardia range, which could be related to pain or anxiety. It should be monitored but does not require urgent follow-up.

E. Taking shallow breaths: Shallow breathing is concerning in a client with rib fractures, as it increases the risk for hypoventilation, atelectasis, and pneumonia. This requires immediate intervention, such as pain management and respiratory support.

F. Alert and oriented to person, place, time, and situation: Cognitive status is normal, so no follow-up is needed.

G. Pain 8 on a 0 to 10 scale: Severe pain limits deep breathing and mobility, increasing the risk of complications. Pain management should be addressed promptly to improve comfort and respiratory function.

H. Blood pressure: 138/82 mm Hg: Slightly elevated, likely related to pain or stress. Monitor trends, but it does not require immediate follow-up at this time.

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Correct Answer is ["A","B","D","G","H"]

Explanation

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.

A. Tremors. B. Urinary retention. C. Blurred vision. D. Diarrhea. E. Drooling.

Correct Answer is ["B","C"]

Explanation

A. Tremors: Benztropine is an anticholinergic used to reduce tremors in Parkinson’s disease, so tremors are not an expected adverse effect of this medication.

B. Urinary retention: Anticholinergic effects of benztropine can decrease bladder contractility, leading to urinary retention, which is a common side effect that clients should monitor.

C. Blurred vision: Benztropine can cause blurred vision due to its anticholinergic effect on the eyes, including pupillary dilation and impaired accommodation. Clients should be cautioned about visual changes.

D. Diarrhea is uncommon with benztropine; in fact, anticholinergic medications more often cause constipation rather than diarrhea.

E. Drooling: Benztropine reduces salivation, so drooling is not expected. The medication may actually help decrease excessive salivation associated with Parkinson’s disease.

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Patient Data Exhibits The nurse is reviewing the client's initial assessment findings. Which assessment findings require follow-up? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is ["A","B","D","G","H"]

Explanation

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Correct Answer is ["B","C"]

Explanation

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Patient Data Exhibits The nurse is reviewing the client's initial assessment findings. Which assessment findings require follow-up? Select all that apply.

Patient Data

Exhibits

The nurse is reviewing the client's initial assessment findings.
Which assessment findings require follow-up? Select all that apply.