The nurse is caring for a client with a history of type 2 diabetes mellitus and hypertension who arrives at the clinic for a scheduled visit. Which finding requires further follow-up by the nurse?
Creatinine: Female: [0.5 to 1.1 mg/dL (44 to 97 µmol/L)], Male: [0.6 to 1.2 mg/dL (53 to 106 µmol/L)]
Blood pressure 130/80 mm Hg.
Serum creatinine 1.6 mg/dL (141.44 µmol/L).
Dark yellow urine.
Difficulty staying asleep.
The Correct Answer is B
Choice A reason: A blood pressure of 130/80 mm Hg is considered high normal and may not require immediate follow-up for a patient with a history of hypertension.
Choice B reason: A serum creatinine of 1.6 mg/dL is above the normal range for both males and females, indicating possible kidney dysfunction, which requires further follow-up.
Choice C reason: Dark yellow urine could be a sign of dehydration, which is common in diabetes, but it is not as concerning as an elevated serum creatinine level.
Choice D reason: Difficulty staying asleep could be related to various factors and may require follow-up, but it is not as urgent as abnormal laboratory values.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Symptoms of heartburn and pain relieved by eating can indeed be consistent with an ulcer, and a complete physical exam can help diagnose the condition and rule out other causes.
Choice B reason: While immediate medical evaluation is important, it is not specified that the symptoms are severe or life-threatening, so it may not be the best initial advice.
Choice C reason: Diet changes can help manage symptoms of heartburn and indigestion, but they may not be sufficient if an ulcer is present.
Choice D reason: It is incorrect to assure the client that the symptoms are only reflux, as ulcer pain can indeed be relieved by food, contrary to the statement.
Correct Answer is ["A","B","C","D"]
Explanation
The client has rested well throughout the night with a continuous positive airway pressure (CPAP) device in place. Sequential devices are in place for venous thromboembolism prevention. The client ambulated 100 yards (91 meters) last night and 200 yards (183 meters) this morning. She reports pain rating of 2 on 0 to 10 scale, located in the abdomen, described as aching. She has tolerated fluids throughout the night with no nausea or vomiting.
Assessment findings
- Neurological Alert and oriented times 4.
- Cardiovascular WNL.
- Respiratory WNL.
- Gastrointestinal/Genitourinary Voided twice throughout night, urine clear amber in appearance. Reports no dysuria. No bowel movement but the client is passing gas.
- Integumentary 4 abdominal incisions from laparoscopic procedure sealed with surgical glue. No drainage, redness, or edema present.
- Musculoskeletal Reported chronic knee pain. 5+ strength in bilateral upper extremities, 5+ strength in bilateral lower extremities.
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