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A nurse is caring for a male client in the emergency department.

Exhibits

The nurse is reviewing the clients electronic medical records
Select the 4 findings that require immediate follow-up.

Upper arm and lower leg findings

Skin temperature

Blood pressure

Bowel sounds

Hgb

Heart rate

Answer and Explanation

Correct Answer : A,C,E,F

Rationale:

A. Upper arm and lower leg findings: The presence of ecchymoses indicates impaired coagulation, which is common in chronic liver disease due to decreased clotting factor production. In the context of active bleeding (hematemesis), this is significant and needs immediate evaluation.

B. Skin temperature: Cool and dry skin, while concerning, is a nonspecific symptom. It may support a diagnosis of hypovolemia or shock, but on its own, it does not require the same urgent intervention as abnormal vital signs or lab results.

C. Blood pressure: A BP of 92/56 mm Hg indicates hypotension and suggests the client may be experiencing hypovolemic shock from gastrointestinal bleeding. This finding requires immediate intervention to prevent end-organ damage.

D. Bowel sounds: Bowel sounds auscultated in all four quadrants suggest that gastrointestinal motility is present. This is not a priority finding and does not indicate an urgent complication.

E. Hgb: A hemoglobin level of 7 g/dL is critically low and consistent with significant blood loss. This value requires immediate follow-up, likely including blood transfusion and identification of the bleeding source.

F. Heart rate: A heart rate of 118/min reflects a compensatory response to hypotension or blood loss. Tachycardia in this setting is a key sign of circulatory compromise and must be addressed immediately.

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Correct Answer is D

Explanation

Rationale:
A. "I can resume sexual intercourse in 48 hours.": Sexual intercourse should be avoided for approximately 3 to 4 weeks after a LEEP to allow proper healing of the cervix and reduce the risk of infection or bleeding. Resuming sexual activity too soon can disrupt tissue recovery.

B. "I can expect some heavy vaginal bleeding for 24 hours.": Heavy vaginal bleeding is not expected after a LEEP and should be reported promptly. Light spotting or a brownish discharge for a few days is normal, but significant bleeding can indicate complications.

C. "I can use tampons when my period comes in a week.": Clients are advised to avoid inserting anything into the vagina, including tampons, for several weeks post-procedure. This helps prevent infection and allows the cervical tissue to heal fully.

D. "I may have mild cramping for several hours.": Mild cramping for a few hours after the procedure is a common and expected response due to cervical manipulation. This symptom typically resolves on its own or with over-the-counter pain relief.

A. Give each screw a quarter turn daily using the wrench provided. B. Apply powder liberally under the chest portion of the halo fixator device. C. Avoid the use of straws when drinking liquids. D. Place a small pillow under the head while lying supine.

Correct Answer is D

Explanation

Rationale:
A. Give each screw a quarter turn daily using the wrench provided: Clients should never adjust or tighten the halo device screws themselves. Only trained medical professionals should handle adjustments to avoid misalignment or injury to the cervical spine.

B. Apply powder liberally under the chest portion of the halo fixator device: Powder can cake and irritate the skin or lead to moisture buildup, increasing the risk of skin breakdown or infection. The skin under the vest should be kept clean and dry, not powdered.

C. Avoid the use of straws when drinking liquids: Clients can safely use straws to drink fluids while wearing a halo device. There is no contraindication for using a straw, and it may actually make drinking easier.

D. Place a small pillow under the head while lying supine: Using a small pillow supports neck alignment and promotes comfort without compromising the stability of the halo device. This is an appropriate and recommended practice during rest.

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A nurse is caring for a male client in the emergency department. Exhibits The nurse is reviewing the clients electronic medical records Select the 4 findings that require immediate follow-up.

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Explanation

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A nurse is caring for a male client in the emergency department.

Exhibits

The nurse is reviewing the clients electronic medical records
Select the 4 findings that require immediate follow-up.