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,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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Bradypnea. Slow respiratory rate is not a typical sign of fluid overload. In fact, fluid volume excess may lead to tachypnea or dyspnea as fluid accumulates in the lungs and impairs gas exchange.
B. Distended neck veins. Jugular vein distention is a classic sign of fluid volume overload. It reflects increased central venous pressure and is commonly seen in clients receiving excessive IV fluids or those with heart failure.
C. Weight loss. IV fluid therapy is intended to increase intravascular volume, and adverse effects are usually related to fluid retention, not loss. Weight gain, not weight loss, would indicate fluid overload.
D. Bradycardia. An increased, not decreased, heart rate (tachycardia) is typically seen with fluid volume excess or in response to fluid shifts. Bradycardia is not a common adverse effect of IV fluid therapy.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}
Explanation
An hCG level of 30,000 IU/L is significantly elevated and may suggest a molar pregnancy, especially when values are higher than expected for gestational age. In a molar pregnancy (hydatidiform mole), trophoblastic tissue proliferates abnormally, producing excessive hCG. This level, in combination with normal hemoglobin and hematocrit, makes other causes like spontaneous or induced abortion less likely.
Key Takeaways:
- Extremely elevated hCG levels can indicate gestational trophoblastic disease (molar pregnancy).
- Molar pregnancy is a nonviable pregnancy characterized by abnormal trophoblast proliferation.
- Normal hemoglobin and hematocrit reduce the likelihood of current bleeding or miscarriage.
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