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A nurse in a medical clinic is caring for a client.

Click to highlight the findings that the nurse should report to the provider. To deselect a finding, click on the finding again.

Nurses' Notes

2 weeks ago, 0940:

Client presents to clinic with reports of feeling unwell for the past few weeks. Client states, "I have a sore that won't get better on my right foot." Client removed gauze bandage to reveal open wound 3 cm x 4 cm on right foot; draining small amount of purulent drainage. Client awake and alert; chest clear to auscultation; heart tones audible with no abnormal heart tones heard. Client reports frequent urination, increased thirst, and recent 4.5 kg (10 lb) weight loss without trying. Client denies pain but reports experiencing nausea. BMI is 27.

Vital Signs

2 weeks ago, 0945:

Temperature 38.3° C (100.9°F)

Heart rate 104/min

Respiratory rate 18/min

Blood pressure 98/74 mm Hg

Oxygen saturation 97% on room air

Laboratory Results

2 weeks ago 1020:

WBC count 9,500/mm3 (5,000 to 10,000/mm3)

Blood glucose 250 mg/dL (74 to 106 mg/dL)

Triiodothyronine (T3) 200 mg/dL (70 to 205 mg/dL)

I have a sore that won't get better on my right foot."

Client removed gauze bandage to reveal open wound 3 cm x 4 cm on right foot

draining small amount of purulent drainage

frequent urination

increased thirst

recent 4.5 kg (10 lb) weight loss without trying

Temperature 38.3° C (100.9°F)

Heart rate 104/min

Blood pressure 98/74 mm Hg

Blood glucose 250 mg/dL (74 to 106 mg/dL)

Answer and Explanation

The Correct Answer is ["C","D","E","F","G","H","I","J"]

Open wound on right foot with purulent drainage: A non-healing wound with purulent drainage suggests infection, which is a major concern in clients with hyperglycemia. Poor wound healing is common in diabetes due to impaired circulation and immune function.
Frequent urination, increased thirst, and unexplained 4.5 kg (10 lb) weight loss: Classic symptoms of hyperglycemia and possible diabetes mellitus. Polyuria and polydipsia result from osmotic diuresis due to high blood glucose levels, while unexplained weight loss may indicate the body breaking down fat and muscle for energy.
Temperature 38.3° C (100.9° F): Fever indicates a possible systemic infection. In diabetic clients, infections can progress rapidly and lead to complications such as cellulitis, osteomyelitis, or sepsis.
Heart rate 104/min: Tachycardia may be a response to fever, dehydration, or underlying infection. Persistent tachycardia could indicate worsening sepsis or hemodynamic instability.
Blood pressure 98/74 mm Hg: While not critically low, this blood pressure is on the lower end and could indicate early signs of dehydration from polyuria or systemic infection.
Blood glucose 250 mg/dL: Significantly elevated blood glucose suggests poor glycemic control, increasing the risk of infection, delayed wound healing, and diabetic ketoacidosis (DKA) if it continues to rise.:

Respiratory rate 18/min: A normal respiratory rate does not indicate respiratory distress or metabolic compensation.
Oxygen saturation 97% on room air: Oxygenation is within the normal range, suggesting no immediate hypoxia.
WBC count 9,500/mm³: Within the normal range, although an infection may still be present given the fever and purulent wound drainage.
Triiodothyronine (T3) 200 mg/dL: Within normal limits, ruling out thyroid dysfunction as a cause of symptoms.
BMI 27: Slightly overweight but not directly contributing to the acute condition.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Reduced cravings: Methadone is a long-acting opioid agonist that helps suppress cravings and withdrawal symptoms in individuals with opioid use disorder. By stabilizing opioid levels in the body, it prevents the compulsive drug-seeking behavior associated with addiction.

B. Somnolence: While methadone can cause sedation, excessive drowsiness is not a therapeutic effect but rather a side effect that may indicate the need for dose adjustment. Therapeutic use should allow normal functioning without excessive sedation.

C. Euphoria: Unlike short-acting opioids, methadone is formulated to prevent euphoria when taken at prescribed doses. Experiencing euphoria may indicate misuse or an excessively high dose rather than a therapeutic response.

D. Dilated pupils: Methadone, as an opioid agonist, typically causes pupil constriction (miosis) rather than dilation. Dilated pupils may indicate withdrawal or intoxication with other substances rather than therapeutic effects of methadone.

A. 1:1 ratio of P to QRS waves B. Absence of P waves C. Prolonged PR interval D. Prolonged QT interval

Correct Answer is B

Explanation

A. 1:1 ratio of P to QRS waves: Atrial fibrillation is characterized by chaotic atrial electrical activity, leading to the absence of distinct P waves. A 1:1 ratio of P to QRS waves is seen in normal sinus rhythm, not atrial fibrillation.

B. Absence of P waves: Atrial fibrillation causes rapid, disorganized atrial depolarization, resulting in the loss of identifiable P waves on ECG. Instead, fibrillatory waves are seen, and the ventricular response is irregularly irregular.

C. Prolonged PR interval: The PR interval represents the time between atrial and ventricular depolarization. In atrial fibrillation, there is no coordinated atrial depolarization, making the PR interval unmeasurable rather than prolonged.

D. Prolonged QT interval: A prolonged QT interval is associated with conditions like electrolyte imbalances, certain medications, and congenital syndromes, but it is not a typical feature of atrial fibrillation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving methadone therapy as treatment for an opioid use disorder. Which of the following findings should indicate to the nurse that the client is experiencing the therapeutic effects of this medication?

Correct Answer is A

Explanation

A nurse is reviewing the results of electrocardiography monitoring for a client who has atrial fibrillation. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

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