A nurse is caring for a client.
The nurse is assessing the client.
Select the 4 findings that require immediate follow-up.
Heart rate
Sleep pattern
Hallucinations
skin turgor
Hygiene
Correct Answer : A,B,C,D
A. Heart rate. The client has a heart rate of 120/min, which is tachycardia and may indicate dehydration, mania-related hyperactivity, or a response to poor nutritional status. This requires immediate follow-up to assess for cardiovascular strain or fluid imbalance.
B. Sleep deprivation (has not slept for 2 days) can exacerbate mania, contribute to delirium, and impair judgment. This requires prompt intervention to ensure safety and stabilization.
C. Hallucinations. The client is responding to internal stimuli, indicating active psychosis, which poses a safety risk to the client and others. Hallucinations require immediate intervention to stabilize mental health and prevent harm.
D. Skin turgor. Poor skin turgor suggests dehydration, which is a priority physiological concern, especially when paired with tachycardia and failure to recall last food intake. This finding indicates the need for fluid and electrolyte evaluation and possible replacement.
E. Poor hygiene is important for overall care but is not an immediate threat to the client’s safety or physiological stability. It can be addressed after urgent medical and psychiatric concerns are managed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Open the outermost flap of the sterile kit toward the body. The outermost flap should always be opened away from the body first to prevent contamination of the sterile field by leaning over it. This helps maintain sterility by minimizing the risk of contact.
B. Place the cap from the solution sterile side up on a clean surface. Placing the cap sterile side up prevents the sterile inner surface from touching the contaminated surface and helps maintain aseptic technique during solution use.
C. Place the sterile dressing within 1.25 cm (0.5 in) of the edge of the sterile field. The outer 2.5 cm (1 inch) border of a sterile field is considered contaminated. Placing items too close to the edge increases the risk of contamination and compromises the field's sterility.
D. Set up the sterile field 5 cm (2 in) below waist level. Any sterile item held or placed below waist level is considered contaminated. The sterile field must always be maintained above waist level to preserve asepsis.
Correct Answer is D
Explanation
A. Fill out an incident report. While completing an incident report is necessary for documentation and quality improvement, it is not the priority action. The nurse must first assess the client's condition to address any immediate risks.
B. Report the incident to the nurse manager. Informing the nurse manager is important for accountability and follow-up, but client safety and assessment come first before escalating the issue to management.
C. Notify the provider. The provider should be informed after the nurse has assessed the client and gathered relevant data such as vital signs. This allows the provider to make informed decisions about further treatment or monitoring.
D. Measure the client's vital signs. Assessing the client is the first priority following a medication error to identify any adverse effects. Vital signs provide immediate data on the client’s physiological status and guide urgent interventions if needed.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.