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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. "I will empty the pouch every 2 to 3 hours.": While it is important to empty the pouch when it is about one-third to half full, emptying it every 2 to 3 hours is unnecessary unless output is extremely high. Frequent emptying is based on the volume of stool, not strict timing.

B. "I will no longer be able to eat nuts.": Clients with a sigmoid colostomy typically resume a normal diet after healing, including nuts, unless otherwise instructed. Nuts are more commonly restricted after ileostomies due to the risk of obstruction, not sigmoid colostomies.

C. "I should expect my stool to be unformed.": Stool from a sigmoid colostomy is usually formed or semi-formed because it comes from the end of the colon where water absorption has mostly occurred. Unformed stool is more characteristic of ileostomies.

D. "I will notify my doctor if the stoma starts to look purple.": A healthy stoma should appear pink to red and moist. A purple, dark, or dusky stoma indicates impaired blood flow or ischemia and requires immediate medical evaluation to prevent serious complications.

A. Ask the client to identify what made them upset B. Assist the client with understanding their needs. C. Place the client in seclusion. D. Administer lorazepam IM.

Correct Answer is A

Explanation

A. Ask the client to identify what made them upset: The first action should be to assess and de-escalate the situation using therapeutic communication. Asking the client to verbalize their feelings can help reduce agitation, promote self-awareness, and prevent escalation.

B. Assist the client with understanding their needs: Helping the client understand their needs is important but comes after first addressing and calming their immediate emotional agitation through assessment and supportive conversation.

C. Place the client in seclusion: Seclusion is a last-resort intervention when the client poses a danger to themselves or others and less restrictive measures have failed. It should not be the first action without attempting de-escalation techniques.

D. Administer lorazepam IM: Administering medication is appropriate if non-pharmacological interventions fail. However, medication should not be the first response before attempting verbal de-escalation strategies in an agitated client.

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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.

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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.