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.

Answer and Explanation

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

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A rationale

The child’s symptoms, including clear and equal lung sounds, a murmur upon auscultation, and clubbing of the fingers, suggest a condition affecting the heart and lungs. Polycythemia, a condition characterized by an increased number of red blood cells, could explain these symptoms. The nurse should monitor the child’s hematocrit and hemoglobin levels, as these can be elevated in polycythemia. The nurse should also monitor the child’s oxygen saturation, as hypoxia can occur in polycythemia3.

Choice B rationale

While temperature is an important vital sign to monitor in any patient, it does not directly address the child’s symptoms or the likely underlying condition. Therefore, it is not the most relevant choice in this scenario3. Diabetic ketoacidosisDiabetic ketoacidosis Explore

A. Prepare the patient for repeat blood cultures. B. Arrange emergency transport to an inpatient facility. C. Explain the need to evaluate liver function. D. Instruct the patient to increase protein intake.

Correct Answer is C

Explanation

Choice A rationale

While repeat blood cultures could potentially provide useful information, they are not the immediate priority when a patient develops jaundice. Jaundice is a sign of liver dysfunction, and further evaluation of liver function is needed to determine the cause and appropriate treatment.

Choice B rationale

Arranging emergency transport to an inpatient facility may be necessary in some cases, but it is not the immediate action required in this situation. The development of jaundice indicates a need for further evaluation, but it does not necessarily indicate an emergency situation.

Choice C rationale

Explaining the need to evaluate liver function is the most appropriate action in this situation. Jaundice is a sign of liver dysfunction, and further evaluation of liver function is needed to determine the cause and appropriate treatment.

Choice D rationale

While increasing protein intake can be beneficial for some patients with liver disease, it is not the immediate priority in this situation. The development of jaundice indicates a need for further evaluation of liver function.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

After traveling to a country with a tropical climate, a young adult is diagnosed with a liver abscess and is taking antimicrobial therapy as an outpatient.During a follow-up visit at the community clinic, the nurse observes that the patient has developed jaundice.Which action should the nurse take?

Correct Answer is C

Explanation

After administering the prescribed albuterol nebulizer treatment, what should the nurse assess?

While caring for a client with a full thickness burn covering 40% of the body surface area (BSA), the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, which of the client’s laboratory values should the nurse note?

A patient with a history of celiac disease has recently been diagnosed with multiple sclerosis.The nurse is preparing to discharge the patient.What is the most important instruction for the nurse to include in the discharge teaching plan?

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A healthcare provider prescribes a low-fiber diet for a patient with ulcerative colitis.Which food selection by the patient indicates to the nurse that the patient understands the prescribed diet?

A nurse is assessing a 3-month-old patient who underwent a pyloromyotomy the previous day.Which of the following findings would indicate a need for pain medication? Select all that apply.