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A nurse is assisting in the care of an adolescent.

The nurse is reviewing the data collection findings.

Select the 5 findings the nurse should report to the provider.

Temperature

Sclera

Bowel sounds

Abdominal tenderness

Anorexia

Breath sounds

Heart rate

Skin

Answer and Explanation

Correct Answer : B,D,E,G,H

Temperature: A temperature of 37.5° C (99.5° F) is within the normal to slightly elevated range and is not high enough to be classified as fever. Therefore, it does not require immediate reporting unless accompanied by other signs of infection or systemic illness.
Sclera: Yellow-tinged sclera suggests jaundice, indicating possible liver dysfunction, which could be related to substance use or hepatitis. Jaundice is a significant clinical finding that requires immediate provider notification for further evaluation and management.
Bowel sounds: Hyperactive bowel sounds are a non-specific finding and can result from gastrointestinal irritation, substance use, or stress. Alone, they do not warrant urgent reporting unless accompanied by more serious signs like severe pain or vomiting.
Abdominal tenderness: Epigastric tenderness could suggest gastrointestinal complications such as hepatitis, pancreatitis, or gastritis, especially in the context of drug use. Abdominal pain on palpation is a concerning symptom that must be reported for further diagnostic workup.
Anorexia: Significant anorexia along with nausea, vomiting, and substance use points to potential systemic illness or gastrointestinal involvement. In adolescents, persistent anorexia is a warning sign that needs prompt evaluation to prevent nutritional deficiencies and worsening health.
Breath sounds: Clear breath sounds are a normal finding and do not require immediate provider notification. There are no respiratory concerns indicated by the lung assessment provided in the notes.
Heart rate: A heart rate of 103/min indicates mild tachycardia, which could be due to dehydration, substance use, or an underlying systemic condition. Tachycardia should be reported to assess if immediate interventions like fluid replacement are necessary.
Skin: Dry skin with poor turgor signals dehydration, a critical finding especially with the reported vomiting and drug use. Dehydration can rapidly worsen and must be addressed by the provider for fluid management and further care.

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Correct Answer is D

Explanation

A. Fats: While fats provide energy and help with cell membrane structure, they are not the primary nutrient required to promote wound healing. Excess fat intake without proper balance may not directly aid in faster tissue repair.

B. Calcium: Calcium is important for bone health and muscle function but does not play a central role in soft tissue wound healing. It is more critical in fracture healing rather than open wound repair.

C. Vitamin D: Vitamin D supports calcium absorption and bone health. Although it contributes to immune function, it is not the main nutrient needed to directly repair skin and soft tissue wounds.

D. Protein: Protein is essential for wound healing because it supports cell growth, tissue repair, and immune function. Adequate protein intake is critical to form new tissue, promote collagen synthesis, and restore skin integrity in clients with open wounds.

A. Provide a surgical mask for the client's partner during visits B. Initiate airborne precautions for the client. C. Tell the client that a cesarean birth is necessary. D. Administer penicillin G to the client immediately

Correct Answer is B

Explanation

A. Provide a surgical mask for the client's partner during visits: While it is important to protect visitors, providing only a surgical mask is insufficient for tuberculosis precautions. Airborne infections like TB require specialized respirators (such as N95 masks), not just standard surgical masks.

B. Initiate airborne precautions for the client: Tuberculosis is an airborne disease, meaning the client must be placed on airborne precautions. This includes placing the client in a negative pressure room and requiring anyone entering to wear an N95 respirator to prevent transmission.

C. Tell the client that a cesarean birth is necessary: Having tuberculosis does not automatically necessitate a cesarean delivery. If the TB is well controlled and the client is noninfectious by the time of labor, vaginal birth is typically safe.

D. Administer penicillin G to the client immediately: Penicillin G is used to treat infections such as syphilis, not tuberculosis. TB requires a specific antibiotic regimen (such as isoniazid, rifampin, ethambutol, and pyrazinamide), not penicillin.

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A nurse is assisting in the care of an adolescent. The nurse is reviewing the data collection findings. Select the 5 findings the nurse should report to the provider.

Nursing Test Bank

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A nurse is assisting in the care of an adolescent. The nurse is reviewing the data collection findings. Select the 5 findings the nurse should report to the provider.

A nurse is assisting in the care of an adolescent.

The nurse is reviewing the data collection findings.

Select the 5 findings the nurse should report to the provider.