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A nurse is caring for a patient in the endocrinologist outpatient clinic.

Exhibits

When completing the assessment at 0810, which of the findings listed below would require a follow-up by the nurse?

Click to highlight the statements in the assessment findings that require follow-up by the nurse.

Axillary temperature 100.5° F

Heart rate 105/min

Respiratory rate 18/min

The client is 34 years of age. States she has a bowel movement after every meal, heat intolerance, and nervousness. The client has lost 20 pounds in the last month without dieting or a change in physical activity. She exercises 4-5 times per week for 45 minutes at a time. States at times during exercise, she experiences irregular heartbeat.

Axillary temperature 100.5° F

Heart rate 105/min

States she has a bowel movement after every meal

heat intolerance, and nervousness

nervousness

The client has lost 20 pounds in the last month without dieting or a change in physical activity

she experiences irregular heartbeat

States at times during exercise

Answer and Explanation

The Correct Answer is ["A","B","C","D","E","F","G"]

The increase in axillary temperature to 100.5° F is significant and could indicate an infection or other inflammatory process. The heart rate has increased to 105/min, which, along with the reported symptoms of heat intolerance, nervousness, and irregular heartbeat during exercise, may suggest an endocrine disorder such as hyperthyroidism. The significant weight loss of 20 pounds in a month without changes in diet or physical activity is also concerning and warrants further investigation. The patient's history of having a bowel movement after every meal could be related to the reported diarrhea and should be explored further.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Beau's lines are horizontal depressions across the nail, unrelated to clubbing.

B. Koilonychia refers to spoon-shaped nails, not convexed nails.

C. Clubbing is a condition where the nails become convex and the angle between the nail bed and finger increases, often associated with chronic hypoxia or lung diseases like COPD.

D. Onycholysis is the separation of the nail from the nail bed, unrelated to convexed nails.

A. Reposition the client every 2 hours. B. Apply compression stockings. C. Ambulate the client at least once per shift. D. Perform hourly skin checks.

Correct Answer is A

Explanation

A. Repositioning every 2 hours is a standard intervention to prevent pressure ulcers and promote circulation.

B. Compression stockings are used for preventing DVTs but do not directly prevent skin breakdown.

C. Ambulation is not feasible for a quadriplegic client.

D. Hourly skin checks can be beneficial but are secondary to preventive measures like repositioning.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While completing a comprehensive assessment of a client who is admitted with chronic obstructive pulmonary disorder, the objective data revealed the client's nails appear convexed and wide with an angle greater than 160 degrees. How would the nurse document this finding?

Correct Answer is C

Explanation

In caring for a quadriplegic client which action would the nurse implement to prevent skin breakdown?

Correct Answer is A

Explanation

The nurse in the trauma unit has received a report on a client who has multiple injuries as a result of a motor vehicle crash. Which action should the nurse plan to take first?

A nurse is assessing a client's peripheral circulation. In which of the following locations should the nurse palpate to assess the posterior tibial pulse? (Selectable areas, or "Hot Spots," are outlined in the artwork below. Select only the outlined area that corresponds to your answer.)

A nurse is assessing an older adult client who is experiencing age-related changes. Which findings should the nurse expect?

A nurse is obtaining a health history from a client that has a serum potassium level of 3.2 mEq (3.5-5.0 mEq). What statements made by the client indicate a potential cause of this clinical manifestation? Select All That Apply.

A client is receiving the diuretic hydrochlorothiazide. When evaluating the client's response to hydrochlorothiazide, which common nontherapeutic response is important for the nurse to monitor?

The client has a prescription for dexamethasone 6 mg IV (intravenous) push STAT. Available is a vial of dexamethasone containing 4 mg/ml. The should draw how many milliliters into the syringe for the dos.

A nurse should ask the client to assume which position to begin the examination of the breast?