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A nurse is reviewing the medical record of a client

Exhibits

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

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

deep tendon reflexes 4+

Heart rate irregular

Bowel sounds hyperactive x 4 quadrants

Generalized weakness with equal bilateral muscle strength and mild leg cramping

Lungs clear

Heart rate 95/min

Alert and oriented to person, place, and time;

Answer and Explanation

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

An irregular heart rhythm could indicate potential cardiovascular issues. Additionally, deep tendon reflexes graded at 4+ suggest hyperreflexia, which may be associated with neurological disorders and should be investigated further.

Hyperactive bowel sounds in all four quadrants could indicate gastrointestinal hypermotility, which might require prompt assessment to determine the underlying cause.

Generalized weakness and mild leg cramping also require follow-up to determine the cause.

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) "His partner has been visiting." - While social support is important, this information is not essential for the receiving unit's immediate care planning.
B) "He is voiding adequately." - While relevant to the client's overall condition, this information may not be a priority for the receiving unit unless there are specific urinary concerns.
C) "He is allergic to sulfa." - Allergy information is critical for ensuring safe medication administration and should be included in the transfer report.
D) "He appears anxious about the transfer." - While the client's emotional state is important, it may not be the most pertinent information for the receiving unit's immediate care planning.

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

A. deep tendon reflexes 4+ B. Heart rate irregular C. Bowel sounds hyperactive x 4 quadrants D. Generalized weakness with equal bilateral muscle strength and mild leg cramping E. Lungs clear F. Heart rate 95/min G. Alert and oriented to person, place, and time;

Correct Answer is ["A","B","C","D"]

Explanation

Hyperactive bowel sounds in all four quadrants could indicate gastrointestinal hypermotility, which might require prompt assessment to determine the underlying cause.

Generalized weakness and mild leg cramping also require follow-up to determine the cause.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is transferring a client to another unit. Which of the following statements should the nurse include in the transfer report?

Correct Answer is C

Explanation

Correct Answer is ["A","B","C","D"]

Explanation

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A nurse is reinforcing teaching with a group of newly licensed nurses regarding client confidentiality. In which of the following situations can the nurse disclose health information without the client's written consent?

A nurse is reinforcing teaching about seizure management with the family of a client who has a seizure disorder. Which of the following statements by a family member indicates an understanding of the teaching?

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A nurse is collecting data from a client who has a stage 4 pressure injury. Which of the following supplies should the nurse obtain?