A nurse is caring for a client who has gastroenteritis and is reviewing the client's findings from two days ago and today. Which of the following findings require immediate follow-up?
The client is confused and appears weak.
The client's oral mucosa is dry and tongue is furrowed.
The client's temperature is 37.4° C (99.3° F).
The client's blood pressure is 90/58 mm Hg.
The Correct Answer is A
Choice A reason: Confusion and weakness are signs of dehydration and electrolyte imbalance, which can result from vomiting and diarrhea. These are serious complications that can affect the client's mental status, blood pressure, heart rate, and kidney function. The nurse should report these findings to the provider and monitor the client's vital signs and fluid status.
Choice B reason: Dry oral mucosa and furrowed tongue are also signs of dehydration, but they are less severe than confusion and weakness. The nurse should report these findings to the provider as well, but they are not the most urgent ones.
Choice C reason: A temperature of 37.4° C (99.3° F) is slightly elevated, but not indicative of a fever or infection. The nurse should document this finding, but it does not require immediate follow-up.
Choice D reason: A blood pressure of 90/58 mm Hg is low, but not hypotensive. The nurse should document this finding, but it does not require immediate follow-up.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Cheddar cheese is not a good food choice for maintaining water intake, as it contains only about 37% water¹. Cheese and other dairy products are also high in sodium, which can increase the water loss through urine.
Choice B reason: Broccoli is a good food choice for maintaining water intake, as it contains about 89% water². Broccoli and other vegetables are also rich in vitamins, minerals, and antioxidants, which can benefit the child's health and hydration.
Choice C reason: Whole-wheat bread is not a good food choice for maintaining water intake, as it contains only about 35% water³. Bread and other grains are also high in carbohydrates, which can increase the water retention in the body.
Choice D reason: Almonds are not a good food choice for maintaining water intake, as they contain only about 4% water⁴. Almonds and other nuts are also high in fat and calories, which can contribute to weight gain and inflammation.
Correct Answer is B
Explanation
Choice B reason: Providing low-fat carbohydrates with meals can help reduce nausea and vomiting in clients who have equilibrium imbalance. Low-fat carbohydrates are easy to digest and can provide energy and prevent hypoglycemia. Examples of low-fat carbohydrates are crackers, toast, rice, and noodles.
Choice A reason: Serving hot foods at mealtime is not a good strategy for clients who have nausea from equilibrium imbalance. Hot foods can have strong odors and flavors that can trigger nausea and vomiting. Cold or room-temperature foods are more tolerable and less stimulating for the senses.
Choice C reason: Encouraging the client to eat even if nauseated is not a helpful strategy for clients who have nausea from equilibrium imbalance. Forcing the client to eat can worsen nausea and vomiting and cause discomfort and distress. The nurse should respect the client's preferences and appetite and offer small, frequent meals and snacks.
Choice D reason: Limiting fluid intake between meals is not a necessary strategy for clients who have nausea from equilibrium imbalance. Fluid intake is important to prevent dehydration and electrolyte imbalance, which can occur due to vomiting. The nurse should encourage the client to drink fluids between meals, but avoid drinking fluids with meals, as this can cause bloating and fullness.
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