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 D
Explanation
Rationale:
A. Small, raised vesicles over the body may indicate an allergic reaction but are not typically associated with IV antibiotics.
B. Rhinitis may indicate an allergic reaction but is not typically associated with IV antibiotics.
C. Itching of the skin may indicate an allergic reaction but is not typically associated with IV antibiotics.
D. Severe wheezing may indicate an allergic reaction or anaphylaxis and should be reported immediately.
Correct Answer is B
Explanation
Rationale:
A. Taking a 1-hour nap each day may disrupt the client's sleep-wake cycle and make it more difficult to sleep at night.
B. Drinking a glass of milk before bedtime can promote sleep because milk contains tryptophan, an amino acid that can help induce sleep.
C. Taking a long walk before bedtime may increase the client's energy level and make it more difficult to sleep.
D. Watching television in bed can disrupt the client's sleep-wake cycle and make it more difficult to sleep.
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