Which four patient assessment findings require follow-up by the nurse? Select all four that apply.
The patient is alert and oriented x4.
The patient reports nausea.
The abdomen is tender to palpation.
The patient is 60 years old.
The patient has dark amber urine.
The patient's oral temperature is 102.4°F.
The patient is voiding without difficulty.
Correct Answer : B,C,E,F
Choice A reason: The patient is alert and oriented x4. This indicates that the patient is fully aware of their surroundings and does not require follow-up for this finding.
Choice B reason: The patient reports nausea. Nausea can be a symptom of many underlying conditions, including gastrointestinal issues or medication side effects, and requires follow-up to determine the cause and provide appropriate treatment.
Choice C reason: The abdomen is tender to palpation. Abdominal tenderness can indicate inflammation, infection, or other abdominal pathology, which requires follow-up to identify the underlying cause and provide appropriate management.
Choice D reason: The patient is 60 years old. This is a demographic detail and does not indicate a medical condition requiring follow-up.
Choice E reason: The patient has dark amber urine. Dark amber urine can be an indication of dehydration or other underlying conditions that require follow-up to identify and address the cause.
Choice F reason: The patient's oral temperature is 102.4°F. A fever indicates the presence of an infection or other health issue that needs to be investigated and managed.
Choice G reason: The patient is voiding without difficulty. This indicates that there are no issues with urinary function, so no follow-up is required for this finding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Teaching the spouse how to assist with transfers and mobility is important for long-term care, but it is not the highest priority at this moment. The focus should be on immediate patient care and assessment.
Choice B reason: Collaborating with physical therapy for gait training is essential for improving the patient's mobility and safety, but it can be scheduled after addressing more urgent needs.
Choice C reason: Monitoring for dysphagia during meals is crucial to prevent aspiration, especially in patients with Parkinson's disease. However, this is a part of ongoing care and not necessarily the immediate priority unless the patient is actively eating.
Choice D reason: Assessing the patient's response to Carbidopa-Levodopa is the highest priority because it directly impacts the patient's overall symptom management. Effective control of Parkinson's symptoms can improve mobility, reduce rigidity, and decrease the risk of complications such as falls and dysphagia.
Choice E reason: Encouraging regular high-calorie, nutrient-dense snacks is important for maintaining the patient's nutritional status, but it is not the immediate priority in comparison to evaluating the effectiveness of medication management.
Correct Answer is ["D","E","F"]
Explanation
Choice A reason: A tongue blade is not typically necessary for a patient with status epilepticus. It is more commonly used for oral care or to check the throat, but it is not essential in this context.
Choice B reason: A urinary catheter is not necessary unless the patient has specific urinary retention issues or requires accurate measurement of urine output. It is not standard equipment for managing status epilepticus.
Choice C reason: A nasogastric tube is not typically required for status epilepticus unless there are specific gastrointestinal issues that need to be addressed. It is not standard equipment for managing status epilepticus.
Choice D reason: A suction set up is essential for a patient with status epilepticus to manage potential airway secretions and prevent aspiration. It ensures that the airway remains clear and reduces the risk of complications.
Choice E reason: An oxygen mask is crucial for a patient with status epilepticus to ensure adequate oxygenation. It helps maintain oxygen levels and supports respiratory function, especially if the patient experiences respiratory distress.
Choice F reason: Side-rail pads are important for patient safety, particularly for a patient with status epilepticus who may be at risk of falls or injury during seizures. They provide a protective barrier and help prevent accidental injury.
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