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The nurse is caring for a client on a medical-surgical unit.

Which of the assessment findings require follow-up by the nurse? Select all that apply.

Orientation

Breath sounds

Gag reflex

Pupils

Extremity circulation

Speech

Grip strength

Thoracic findings

Heart sounds

Answer and Explanation

Correct Answer : A,C,F,G

A. Orientation: The client is alert only to name and not fully oriented, indicating acute neurological changes. This requires immediate follow-up to assess for possible stroke or other neurological compromise.

B. Breath sounds: Breath sounds are vesicular and bronchovesicular with full thoracic excursion, which is within normal limits. No follow-up is immediately required.

C. Gag reflex: The absence of a gag reflex is a significant finding, increasing the risk of aspiration and airway compromise. Immediate assessment and interventions are necessary to protect the airway.

D. Pupils: Pupils are equal and reactive bilaterally, which is within normal limits. No follow-up is required for this finding.

E. Extremity circulation: Pulses are +2 with capillary refill less than 2 seconds in all extremities, indicating adequate perfusion. No follow-up is needed at this time.

F. Speech: The client’s speech is unintelligible, indicating acute neurological compromise. This requires urgent follow-up and possible intervention for stroke or transient ischemic attack.

G. Grip strength: Decreased grip strength in the right upper extremity indicates motor deficits consistent with neurological injury, requiring immediate assessment and intervention.

H. Thoracic findings: Full and symmetric thoracic excursion with normal breath sounds is within normal limits, requiring no follow-up.

I. Heart sounds: S1 and S2 are present, and the cardiac monitor shows sinus tachycardia without additional abnormalities, which does not require immediate follow-up.

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Correct Answer is D

Explanation

A. Heart rate 98/min: A heart rate of 98 beats per minute is within normal limits (60–100/min) for adults. While it is at the upper end of normal, it does not typically require urgent reporting or intervention.

B. Widened P wave: A widened P wave may indicate atrial enlargement or conduction delay, which is important to note, but it is not immediately life-threatening. It should be documented and monitored, but it does not necessitate urgent notification.

C. 2 PVCs/min: Occasional premature ventricular contractions (PVCs) can occur in healthy individuals or as a response to stress, caffeine, or electrolyte imbalances. Two PVCs per minute is usually not critical unless associated with symptoms or patterns like couplets or runs of ventricular tachycardia.

D. S-T segment elevations: ST-segment elevation is a significant finding that can indicate acute myocardial injury or infarction. This is a medical emergency requiring immediate notification of the provider for rapid assessment, intervention, and potential reperfusion therapy.

A. “I will overarticulate words when speaking." B. “I will repeat words not heard by the client C. “I will speak in a loud voice when addressing the client." D. “I will face the client when speaking”

Correct Answer is D

Explanation

A. “I will overarticulate words when speaking.": Overarticulating words can distort speech and make it more difficult for a client with hearing loss to understand. Clear, normal articulation combined with visual cues is more effective for communication.

B. “I will repeat words not heard by the client": Repeating words is useful, but it is a secondary strategy. Effective communication begins with proper positioning and visual cues, which enhance understanding before repetition is needed.

C. “I will speak in a loud voice when addressing the client.": Speaking louder does not necessarily improve comprehension and can distort speech. Many clients with hearing loss benefit more from clear, normal-volume speech and lip-reading rather than increased volume.

D. “I will face the client when speaking": Facing the client allows them to use visual cues, such as lip reading and facial expressions, which significantly improves understanding. This technique is the primary and most effective communication strategy for clients with hearing loss.

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The nurse is caring for a client on a medical-surgical unit.

Which of the assessment findings require follow-up by the nurse? Select all that apply.