The same patient reports that he was able to sleep through the night.
However, he notes continued numbness in his left arm, along with a tingling sensation, and is not able to move his fingers.
He also reports mild nausea and has no desire to eat breakfast.
There is a 3 cm by 5 cm area of blood noted on the bandage.
His left arm is warm to touch.
His left shoulder and collarbone are symmetric.
As a nurse, which findings would indicate that the patient is progressing as expected?
The patient was able to sleep through the night.
The patient’s left arm is warm to touch.
The patient’s left shoulder and collarbone are symmetric.
The patient has no desire to eat breakfast.
Correct Answer : A,B,C
Choice A rationale
The patient was able to sleep through the night. This is a positive sign as it indicates that the patient is comfortable and not in distress. Sleep is essential for healing and recovery.
Choice B rationale
The patient’s left arm is warm to touch. This could indicate that there is adequate blood flow to the area, which is necessary for healing. However, warmth could also be a sign of inflammation or infection, so it’s important to monitor this closely.
Choice C rationale
The patient’s left shoulder and collarbone are symmetric. This is a good sign as it indicates that there is no obvious dislocation or fracture, which could cause pain and limit mobility.
Choice D rationale
The patient has no desire to eat breakfast. This is not necessarily a sign of progress. Loss of appetite can be a symptom of many conditions, including stress, infection, or certain medications. It’s important to encourage the patient to eat to maintain strength and support healing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Printing the electronic medical record (EMR) from the backup server may not be the most immediate action required. While having a backup of the EMR is important, it does not address the immediate issue of the system failure.
Choice B rationale
Waiting for notification that the system has been rebooted is a passive approach and may not be the most effective initial action. It does not address the immediate need to communicate the issue to the appropriate department.
Choice C rationale
Identifying information as a late entry in the record is a documentation practice that is used when charting is not completed in a timely manner. However, this action does not address the immediate issue of the system failure.
Choice D rationale
Notifying the information services department of the situation is the correct action. This allows the appropriate department to begin troubleshooting and resolving the issue. In the event of a system failure, the first step should be to report the issue so that it can be addressed as quickly as possible.
Correct Answer is ["A","B","D"]
Explanation
.Administer a stool softener: This could be a good option to consider, as the client has not had a bowel movement since the surgery. However, the nurse should first consult with the healthcare provider before administering any new medications.
B.Ask the client about their normal bowel routine: This is a good action to take. Understanding the client’s normal bowel routine can provide valuable context for the current situation.
C.Hold the client’s next meal: This may not be necessary at this point. The client’s regular diet has been ordered by the provider, and there’s no indication of nausea, vomiting, or other symptoms that would necessitate holding meals.
D.Perform a digital rectal exam: This could be considered if there’s a concern about impaction or other complications. However, this should only be done after consulting with the healthcare provider.
E.Discontinue morphine: This is not advisable based on the information provided. The client is reporting uncontrolled pain, and morphine has been ordered by the provider for pain management. Any changes to pain medication should be discussed with the healthcare provider.
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