A nurse is caring for a client.

Exhibits

The nurse is assessing the client.

Select the 4 findings that require immediate follow-up.

Heart rate

Sleep pattern

Hallucinations

skin turgor

Hygiene

Answer and Explanation

Correct Answer : A,C,D,E

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 pattern. While lack of sleep is concerning and a clear symptom of mania, it is a behavioral health issue that typically does not require immediate physiological intervention unless it leads to severe exhaustion or psychosis. It should be addressed, but is not the top priority.
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. Hygiene. The client's unclean appearance reflects self-neglect, a common feature of psychiatric decompensation, and may indicate inability to meet basic needs. This requires prompt attention to prevent complications like infection and assess for functional impairment, though it is secondary to life-threatening physiological or safety concerns.

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Correct Answer is B

Explanation

A. Calories. Significant increases in caloric intake are not necessary during the first trimester. Most women do not require additional calories until the second and third trimesters, when fetal growth accelerates.
B. Folate. Folate (or folic acid) is crucial during early pregnancy, particularly in the first trimester, to prevent neural tube defects such as spina bifida. Women are advised to increase folate intake before conception and during early pregnancy.
C. Calcium. Calcium needs increase later in pregnancy when the fetus's bone development intensifies. While important throughout pregnancy, calcium is not the most critical nutrient to increase specifically in the first trimester.
D. Protein. Protein is essential for fetal growth, but increased protein needs become more important in the second and third trimesters when fetal tissue development peaks. Early pregnancy focuses more on folate supplementation for neural development.

A. "I will plan to spend time tanning between 10 a.m. and 2 p.m." B. "I will use an indoor tanning bed instead of going outside." C. "I will use sunblock with an SPF of 10 when I am outdoors." D. "I will apply sunscreen before and after swimming

Correct Answer is D

Explanation

A. "I will plan to spend time tanning between 10 a.m. and 2 p.m." UV radiation from the sun is strongest between 10 a.m. and 4 p.m., and sun exposure during this time significantly increases the risk of skin cancer. Outdoor activity should be minimized during peak hours.
B. "I will use an indoor tanning bed instead of going outside." Indoor tanning beds expose users to intense UV radiation, which also increases the risk of skin cancer. They are not a safer alternative to natural sunlight and should be avoided.
C. "I will use sunblock with an SPF of 10 when I am outdoors." SPF 10 provides minimal protection and is not adequate for skin cancer prevention. The recommended SPF is 30 or higher, applied generously and re-applied regularly.
D. "I will apply sunscreen before and after swimming." Sunscreen should be applied 15 to 30 minutes before sun exposure and re-applied every 2 hours, especially after swimming or sweating. This statement shows an understanding of proper sun protection practices.

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A nurse is caring for a client. Exhibits The nurse is assessing the client. Select the 4 findings that require immediate follow-up.

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A nurse is caring for a client.

Exhibits

The nurse is assessing the client.

Select the 4 findings that require immediate follow-up.