A nurse is reviewing the medical record of a client.
Click to highlight below the findings that require immediate follow-up.
Body system/Findings
Neurological- Alert and oriented to person, place, and time; deep tendon reflexes 4+
Musculoskeletal - Generalized weakness with equal bilateral muscle strength and mild leg cramping
Respiratory- Lungs clear
Cardiovascular- Heart rate irregular: Heart rate 95/min
Gastrointestinal- Bowel sounds hyperactive x 4 quadrants
Neurological- Alert and oriented to person, place, and time; deep tendon reflexes 4+
Musculoskeletal - Generalized weakness with equal bilateral muscle strength and mild leg cramping
Respiratory- Lungs clear
Cardiovascular- Heart rate irregular: Heart rate 95/min
Gastrointestinal- Bowel sounds hyperactive x 4 quadrants
The Correct Answer is ["D","E"]
Rationale:
A. These neurological findings are within normal limits and do not require immediate follow-up.
B. These musculoskeletal findings are not indicative of an emergency and can be addressed during routine care.
C. Clear lung sounds are a normal finding and do not require immediate follow-up.
D. An irregular heart rate may indicate an arrhythmia or other cardiovascular issue that requires further assessment and intervention.
E. Hyperactive bowel sounds can indicate a variety of gastrointestinal issues, including bowel obstruction or ileus, which may require immediate intervention or further investigation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}
Explanation
A. Despite the client reporting thirst and frequent urination, the client's urine specific gravity of 1.010 is within the normal range (1.005 to 1.030). The above symptoms could be associated with the hyperglycemia.
B. There is no indication of a pneumothorax in the nurse's notes or diagnostic results.
C. The casual glucose level of 300 mg/dL is significantly above the normal range (less than 200 mg/dL), indicating hyperglycemia.
D. The client’s WBC level is elevated, 11,500/mm3 (5,000 to 10,000/mm3) thus indicating an infection.
Correct Answer is D
Explanation
Rationale:
A. Bowling is a low-impact activity that may not provide the weight-bearing exercise needed to help prevent osteoporosis.
B. Jogging is a high-impact activity that may not be appropriate for an older adult at risk for osteoporosis due to the potential for joint and bone stress.
C. Passive range-of-motion exercises are not weight-bearing and may not provide the same benefits as weight-bearing exercise.
D. Walking is a weight-bearing exercise that can help to increase bone density and reduce the risk of osteoporosis.
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