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A nurse in a provider's office is caring for a client.

Which of the following findings require follow-up? Select all that apply.

Hematocrit

Oxygen saturation

Activity level

Blood pressure

Temperature

Breath sounds

Pain level

Vitamin B12 level

Answer and Explanation

Correct Answer : A,B,C,D,H

Hematocrit: The client's hematocrit level of 24% is significantly low (normal range: 37% to 47%), indicating anemia. This requires follow-up to determine the underlying cause and initiate appropriate treatment, such as iron supplementation or further investigation.
Oxygen saturation: An oxygen saturation level of 94% is slightly low, especially considering the client's reported shortness of breath. Monitoring is necessary to ensure adequate oxygenation and to assess if supplemental oxygen or further respiratory evaluation is needed.
Activity level: The client reports generalized weakness and increased fatigue, particularly becoming short of breath after minimal exertion (e.g., climbing stairs). This decreased activity level is concerning and may indicate cardiovascular or hematological issues, requiring further assessment and follow-up.
Blood pressure: The blood pressure readings indicate orthostatic hypotension, with a drop from 118/60 mm Hg sitting to 102/50 mm Hg standing. This significant drop suggests potential volume depletion or anemia, which requires follow-up to assess fluid status and ensure safety during ambulation.
Vitamin B12 level: The Vitamin B12 level of 159 pg/mL is slightly below the normal range (160 to 950 pg/mL), indicating potential deficiency. This can lead to anemia and neurological issues. Follow-up is needed to evaluate dietary intake and consider supplementation.

Temperature: The client's temperature of 37° C (98.6° F) is within normal limits and does not indicate a need for follow-up. Monitoring for signs of infection or inflammation is important, but this finding is stable.
Breath sounds: The assessment shows clear and present bilateral breath sounds, which indicate no respiratory distress or abnormalities. This finding does not require follow-up.
Pain level: The client reports no pain or discomfort, which is a positive finding and does not necessitate further follow-up. Ongoing assessment for pain should continue, but current findings are stable.

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Correct Answer is B

Explanation

A. Graham crackers: Hard, crunchy foods can trigger pain by irritating the trigeminal nerve, making them unsuitable for clients with trigeminal neuralgia. Soft, easy-to-swallow foods are preferred.

B. Vanilla pudding: Soft, smooth-textured foods are recommended to minimize irritation of the trigeminal nerve. Vanilla pudding requires minimal chewing, reducing the risk of triggering pain.

C. Ice cream: Extremely cold foods can act as a trigeminal nerve irritant and may provoke pain episodes. Lukewarm or room-temperature foods are preferable.

D. Vegetable soup: Although liquid-based, vegetable soup often contains solid pieces that require chewing, which can increase the risk of triggering pain. Blended or pureed soups are a better option.

A. Increased body hair B. Decreased blood urea nitrogen level C. Hyperpigmentation of the skin D. Hypocalcemia

Correct Answer is C

Explanation

A. Increased body hair: Adrenal insufficiency leads to decreased androgen production, which may cause hair thinning rather than increased body hair. Hypertrichosis (excessive hair growth) is not a typical finding in adrenal insufficiency.

B. Decreased blood urea nitrogen level: Adrenal insufficiency is often associated with dehydration due to aldosterone deficiency, leading to reduced sodium retention and increased fluid loss. This can result in elevated blood urea nitrogen (BUN) levels rather than a decrease.

C. Hyperpigmentation of the skin: Increased melanocyte-stimulating hormone (MSH) activity, triggered by elevated adrenocorticotropic hormone (ACTH) levels, causes darkening of the skin, especially in sun-exposed areas, skin folds, and mucous membranes. This is a hallmark feature of primary adrenal insufficiency (Addison’s disease).

D. Hypocalcemia: Adrenal insufficiency is more commonly associated with hypercalcemia rather than hypocalcemia. Decreased cortisol levels can lead to reduced renal calcium excretion, contributing to elevated serum calcium levels.

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A nurse in a provider's office is caring for a client. Which of the following findings require follow-up? Select all that apply.

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A nurse in a provider's office is caring for a client.

Which of the following findings require follow-up? Select all that apply.