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 B
Explanation
Rationale:
A. Holding an object away from the body may increase the strain on the back muscles and increase the risk of injury.
B. Tightening the abdominal muscles helps provide support for the back and reduces the risk of injury.
C. Bending at the waist can strain the back muscles and increase the risk of injury. The correct technique is to bend at the knees and hips while keeping the back straight.
D. Keeping legs straight while lifting can increase the strain on the back muscles and increase the risk of injury. The correct technique is to bend at the knees and hips while keeping the back straight.
Correct Answer is D
Explanation
Rationale:
A. This response is dismissive and may not address the client's concerns about discussing their decision with loved ones.
B. This response is judgmental and may not support the client's autonomy in making healthcare decisions.
C. This response is dismissive and may not address the client's concerns about discussing their decision with loved ones.
D. This response acknowledges the client's decision and supports the client in discussing their decision with loved ones.
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