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A nurse in an outpatient mental health clinic is caring for a client. Select the 3 findings that require immediate follow-up.

Weight

Neuro status

Auditory hallucinations

Speech

Restlessness

Answer and Explanation

Correct Answer : B,C,E

The correct answer is B, C, and E.

A. Weight is not a correct choice because it is not a vital sign and it does not indicate an acute change in the client's condition.
B. Neuro status is a correct choice because it reflects the client's level of consciousness, orientation, memory, and cognitive function. Any alteration in neuro status could indicate a serious problem such as infection, stroke, or medication toxicity.
C. Auditory hallucinations are a correct choice because they are a symptom of psychosis and could indicate a relapse or worsening of the client's mental illness. Auditory hallucinations could also impair the client's ability to cope, communicate, and function effectively.
D. Speech is not a correct choice because it is not a vital sign and it does not indicate an acute change in the client's condition. Speech could be affected by various factors such as mood, anxiety, or medication side effects.
E. Restlessness is a correct choice because it is a sign of agitation, anxiety, or discomfort. Restlessness could also indicate an underlying physical or psychological problem such as pain, infection, or psychosis.

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Correct Answer is ["B","C","E","F"]

Explanation

A. Bowel sounds are hypoactive in all four quadrants, which is expected after an appendectomy due to anesthesia and decreased peristalsis. This is not a finding that needs to be reported to the provider.
B. Oxygen saturation is 93% on room air, which is below the normal range of 95% to 100%. This could indicate impaired gas exchange, respiratory depression, or infection. This is a finding that needs to be reported to the provider.
C. Nausea is a common feature of appendicitis and should go away with appendectomy. This finding should, therefore, be reported to the healthcare provider.
D. Vomiting is also a common side effect of morphine and anesthesia, and can be managed with antiemetics and fluids. This is not a finding that needs to be reported to the provider unless it persists or interferes with oral intake.
E. Pain level is 6 on a scale of 0 to 10.The client received morphine as prescribed at 1815, and the pain level is still significant. This isa finding that needs to be reported to the provider
F. Heart rate is 110/min, which is above the normal range of 60 to 100/min. This could indicate pain, anxiety, dehydration, infection, or bleeding. This is a finding that needs to be reported to the provider.
G. Incision characteristics are clean and dry, which is expected after an appendectomy. However, the nurse should monitor for signs of infection such as redness, swelling, warmth, drainage, or odor. This is a finding that needs to be reported to the provider if any signs of infection are present.
H. Lungs sounds are clear on auscultation, which is expected after an appendectomy. However, the nurse should encourage deep breathing and coughing exercises to prevent atelectasis and pneumonia. This is a finding that needs to be reported to the provider if any abnormal lung sounds are heard such as crackles, wheezes, or diminished breath sounds.

A. Measuring the group's work against the assigned objectives B. Noting the progress of the group toward assigned goals C. Sharing experiences as an authority figure D. Offering new and fresh ideas on an issue

Correct Answer is B

Explanation

- A. Incorrect. Measuring the group's work against the assigned objectives is a task role that belongs to the evaluator, who assesses the quality and effectiveness of the group's performance.

- B. Correct. Noting the progress of the group toward assigned goals is a task role that belongs to the orienteer, who keeps track of where the group is heading and summarizes what has been accomplished.

- C. Incorrect. Sharing experiences as an authority figure is a task role that belongs to the information giver, who provides factual data or personal knowledge to the group.

- D. Incorrect. Offering new and fresh ideas on an issue is a task role that belongs to the initiator, who proposes new solutions or approaches to problems.

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A nurse in an outpatient mental health clinic is caring for a client. Select the 3 findings that require immediate follow-up.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["B","C","E","F"]

Explanation

A nurse is assigning task roles for a group of clients in a community mental health clinic. Which of the following tasks should the nurse assign to the member of the group functioning as the orienteer?

Correct Answer is B

Explanation

A nurse is assessing a client who has pulmonary edema. Which of the following findings should the nurse expect?

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A nurse is caring for a client who has a fecal impaction. Which of the following actions should the nurse take when digitally evacuating the stool?

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