A nurse is caring for a client in an emergency department (ED).
Exhibits
Which of the following findings in the client's medical record requires follow-up by the nurse? Select all that apply

Blood pressure

Syncope

ECG

Albumin

Answer and Explanation

Correct Answer : A,B,C,D,E,F

Rationale:

A. Blood pressure: Orthostatic hypotension is evident from the drop in systolic and diastolic pressure when standing, indicating fluid and electrolyte imbalance. This may reflect volume depletion due to purging and requires monitoring to prevent fainting or falls.

B. Syncope: The client reports repeated fainting episodes, a red flag when paired with orthostatic hypotension and electrolyte disturbances. This suggests unstable cardiovascular status and raises the risk of injury or sudden cardiac events.

C. ECG: Sinus tachycardia with premature ventricular contractions indicates cardiac irritability likely due to electrolyte imbalance, especially hypokalemia. Continuous cardiac monitoring and correction of abnormalities are needed.

D. Albumin: An albumin level of 2.6 g/dL indicates significant malnutrition and protein deficiency, compromising immune function and wound healing. This also suggests a chronic issue requiring dietetic intervention and nutritional rehabilitation.

E. Potassium: Potassium at 3.0 mEq/L is dangerously low and a known contributor to cardiac arrhythmias and muscle weakness. Replenishment and close monitoring are critical to avoid complications such as cardiac arrest.

F. Sodium: Although sodium is only slightly low at 134 mEq/L, in the context of purging and poor intake, this could indicate dilutional hyponatremia. It increases seizure risk and needs assessment of fluid status and intake behaviors.

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Correct Answer is D

Explanation

Rationale:

A. Monitor the client for hypoglycemia: Hypoglycemia is not a common complication of bacterial meningitis. More relevant concerns include increased intracranial pressure, fever, and potential neurological damage, rather than altered glucose metabolism.

B. Perform range-of-motion exercises once per shift: While maintaining mobility is important, this is not a priority during the acute phase of bacterial meningitis. The client may be photophobic, confused, or in too much discomfort for routine exercises early in treatment.

C. Place the client in high-Fowler's position: High-Fowler’s can increase discomfort and may worsen meningeal irritation. A more appropriate position is 30 degrees with head midline to promote venous drainage and reduce intracranial pressure.

D. Implement seizure precautions: Seizures are a potential complication of bacterial meningitis due to inflammation, increased intracranial pressure, and irritation of the cerebral cortex. Seizure precautions are a critical safety measure in the acute phase of care.

A. Assist the adolescent in applying for Medicaid. B. Refer the adolescent to local mental health clinic C. Contact the adolescent parent for assistance D. Advise the adolescent to place the newborn for adoption

Correct Answer is A

Explanation

Rationale:

A. Assist the adolescent in applying for Medicaid: Medicaid can provide essential prenatal care, delivery services, and pediatric coverage for low-income individuals. Helping the adolescent apply addresses both her financial and health concerns, supporting positive outcomes.

B. Refer the adolescent to local mental health clinic: While emotional support is important, this action doesn’t directly address her stated concern about affording and caring for the baby. It may be appropriate later but is not the immediate priority.

C. Contact the adolescent parent for assistance: Contacting family may be helpful if the adolescent consents, but it must respect her autonomy and confidentiality. It is not the nurse’s first step without permission or expressed need for family involvement.

D. Advise the adolescent to place the newborn for adoption: Suggesting adoption without the adolescent initiating that discussion may be inappropriate and coercive. Nurses should provide options neutrally and supportively, not direct decisions about parenting or adoption.

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A nurse is caring for a client in an emergency department (ED).Exhibits Which of the following findings in the client's medical record requires follow-up by the nurse? Select all that apply

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A nurse is caring for a client in an emergency department (ED).
Exhibits
Which of the following findings in the client's medical record requires follow-up by the nurse? Select all that apply