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A nurse is caring for a client who presents to the emergency department.

Exhibits
A nurse is reviewing the client's record. Which of the following client findings indicate the need for further evaluation?
(Select All that Apply.)

A.

Weight

B.

Report of cough

C.

Blood pressure

D.

Travel history

E.

Sputum characteristics

F.

Temperature

G.

Heart Rate

Answer and Explanation

Correct Answer : A,D,E,F,G

Based on the information provided, the nurse should consider the following client findings for further evaluation:

A. Weight: The client's weight loss of 5 pounds (2.26 kg) over the last week needs further evaluation as it could be indicative of an underlying health issue.

D. Travel history: The client's recent travel to South Africa and the presence of respiratory symptoms raises concerns about possible exposure to infectious diseases, including tuberculosis, which is more prevalent in certain regions. Further evaluation of the travel history is essential.

E. Sputum characteristics: The client's report of "blood-tinged sputum" is concerning and should be evaluated further to rule out potential serious respiratory conditions.

F. Temperature: The presence of a "low-grade fever" should be further evaluated to assess the possible infectious etiology of the client's symptoms.

G. Heart Rate: The heart rate should be assessed further as an elevated heart rate could indicate an underlying systemic infection or other health issues.

The following client findings do not necessarily indicate the need for further evaluation in this context:

B. Report of cough: The client's report of a cough is the primary reason for their presentation to the emergency department and will, of course, be further evaluated as part of the assessment.

C. Blood pressure: Though monitoring blood pressure is essential, the information provided does not indicate any specific concerns regarding the client's blood pressure at this point.

A comprehensive assessment and further evaluation are necessary to determine the underlying cause of the client's symptoms. The nurse should collaborate with other healthcare professionals to conduct appropriate diagnostic tests and investigations to establish a diagnosis and provide appropriate care.


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Related Questions

Correct Answer is ["A","B"]

Explanation

Client states "I’m feeling much better." They report less fatigue even though they have difficulty sleeping. Client reports they are not sad anymore but are experiencing more frequent headaches. Client continues to deny any suicidal ideation
Vital Signs
Today
BP 149/91 mm Hg

Heart rate 75min

Respiratory rate 18/min

Explanation:

Based on the provided information, the following findings indicate the client may be experiencing adverse effects of the medication (fluoxetine):

  1. Increased headaches: The client reports experiencing more frequent headaches, which can be an adverse effect of fluoxetine.

  2. Difficulty sleeping (hypersomnia): The client reports difficulty sleeping despite feeling less fatigued, which could be related to the medication's effect on sleep patterns.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"}}

Explanation

Rationale:

• Obtain daily weights: Daily weights are used to monitor fluid balance in conditions like preeclampsia or heart failure. In this acute preterm labor scenario, the priority is monitoring fetal well-being and uterine activity, not long-term fluid shifts.

• Administer terbutaline: Terbutaline is a tocolytic medication used to suppress preterm labor by relaxing uterine smooth muscle. Given the client’s regular, strong contractions at 33 weeks with cervical changes, terbutaline may be prescribed to delay labor and allow fetal maturation.

• Administer oxytocin: Oxytocin stimulates uterine contractions and is used to induce or augment labor. In a client experiencing preterm labor at 33 weeks, oxytocin is contraindicated because it could worsen labor progression and increase risk of preterm birth.

• Administer betamethasone: Betamethasone is a corticosteroid administered to accelerate fetal lung maturity when preterm birth is imminent. Since the client is 33 weeks gestation and showing signs of preterm labor, administration is anticipated to reduce neonatal respiratory complications.

• Maintain modified bed rest with bathroom privileges: Modified bed rest can help reduce uterine stimulation, conserve energy, and support uteroplacental perfusion in clients experiencing preterm labor. Limiting physical activity is a standard intervention for preterm labor management.

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